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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, April 27, 2015

Dog Bite/ Rabies: Things what you need to know

This week, I have a podcast for you. 

We are going to talk about Dog Bite/Rabies. The reason I chose this topic is because this is something which is still fairly common in India (Dog Bite) and the incidence of rabies in India has now been constant for about a decade. One of the reasons for this is poor knowledge of post exposure prophylaxis among medical professionals. I take you through the national guidelines for treating dog bites (Indian Guidelines).  I hope this will help to change the scenario:

Listen to the podcast. 
Find the show notes attached.

Thanks!










Monday, April 20, 2015

Lets delve into the Blood Culture!


Blood Culture is a common investigation that is done everyday in the Emergency Departments. It plays an integral role in the evaluation of sepsis. Culture media used in the blood culture bottles can grow most of the important species of bacteria/fungi. Our goal is to find out if the organisms are present in the patient’s blood stream or not. 




If proper technique is not used, false positive results occur where skin commensals grow instead of the pathogens. Therefore, maintaining asepsis is vital when taking blood culture. Bacteremia is often associated with fever, so it is always recommended to take blood culture during an episode of fever. But overall, the indications of blood culture are broad and not clearly defined.

Indications for blood culture:
1. Clinical features of sepsis including tachycardia, tachypnea, increased or sub-normal temperature and change in sensorium, hypotension 
2. Suspicion of infective endocarditis
3. Pyrexia of unknown origin
4. Unexplained leucocytosis or leucopenia
5. Systemic and localised infections including suspected meningitis, osteomyelitis, septic arthritis, acute untreated bacterial pneumonia or other possible bacterial infection

Types of Blood Culture Bottles



  1. Yellow top – paediatric aerobic 
  2. Green top – adult aerobic 
  3. Orange top – anaerobic 
  4. Black top – mycobacteria 
  5. Silver top – mycoplasma 

Procedure

1 Verify the patient’s identity and obtain verbal consent

2 Assemble the correct materials required for blood culture:
• blood culture bottle(s), syringe (10 ml or more), needle (22 gauge or more)
• sterile gloves, tourniquet, adhesive strip, skin disinfectant
• sterile pack containing cotton/gauze swabs, sterile paper x2 and waste bag
• patient labels, sharps waste disposal bin.

3 Open the sterile blood culture pack onto the trolley. 

4 Apply tourniquet and select a suitable vein. Wash hands with soap and water or disinfect with alcohol hand disinfectant. Dry your hands or rub the hand disinfectant in until dry. Apply sterile gloves.

5 Clean the puncture site three times with skin disinfectant using aseptic technique. Allow 1 - 2 minutes for the disinfectant to dry. Drape the area. 

6 Collect a minimum of 10 ml of blood (adults). If using the vacutainer system, the blood culture must be the first blood specimen to be collected. The rate of isolation of micro-organisms from blood is directly related to the volume of blood collected.

7 Release tourniquet. Remove needle and syringe from puncture site and place dry swab on puncture site and apply pressure. Before inoculating the sample into the culture bottle, first disinfect the top of the blood culture bottle with an alcohol swab. If blood is being collected for other tests, always inoculate blood culture bottle first. Changing needles between blood sample collection and inoculation of blood culture bottle is controversial (I don’t recommend it), and if you are doing this beware of needle-stick injury. 

8 Gently rotate the blood culture bottle to mix the blood and culture medium (do not shake vigorously).

9 Label the blood culture bottle and complete a laboratory request form. Remember to include the site, date and time of collection, full clinical information regarding the suspected diagnosis, and contact details for the clinician responsible for the patient.

10 Deliver the blood culture bottle to the laboratory ASAP. If there is a delay in getting the sample to the laboratory, do not refrigerate the bottle; rather leave it at room temperature.



Issues to contemplate:

1. Can we collect blood cultures from indwelling catheters?
Blood should not be collected from indwelling arterial or venous lines unless an infected intravenous line is suspected. Should blood be drawn for culture from an indwelling line, a second specimen should be obtained from a peripheral site.

2. How many sets we need?
Ideally 2 sets i.e. 2 aerobic (10+10=20ml) and 2 anaerobic (10+10=20ml) cultures, although routine use of anaerobic culture bottles in controversial. Two or more blood specimens should be collected using sterile technique at separate sites, if possible before administering antibiotics. If all 4 sets are negative after 24 hours and sepsis is still suspected, more cultures may be collected. A larger number of cultures may have to be collected from persons already receiving antimicrobials although, if clinical condition allows, stopping antibiotics and re-culturing after 48 hours is preferred.

3. How much blood is enough?
Ideally, a minimum of 10 ml of blood, depending on the blood culture system used, should be inoculated into a culture bottle when taking blood from adults. For Pediatrics, draw 1 mL/year of age. Adequate volumes of blood improve detection of pathogenic organisms and reduce time to detection. The rate of isolation of micro-organisms from blood is directly related to the volume of blood collected. The yield in adults increases approximately by 3% per ml of blood cultured.


4. Is there a difference between arterial and venous blood culture samples?
Arterial blood culture provides no advantage over venous samples.

5. What are ways by which we can reduce contamination?
Important ways to decrease contamination of blood culture bottles include the use of tincture of iodine as a disinfectant, avoidance of drawing blood through existing intravenous lines, disinfecting the membrane of the blood culture bottle and using sterile gloves during the procedure. Also, the initial collection should be with a peripheral venipuncture (not through a line) if possible.


Key Points:




Monday, April 13, 2015

Modern Management of Sepsis - May be less is more!


Hi,

It would not be fair if we don't do a post on sepsis after the completion of the sepsis trio -  ARISE, PROCESS and PROMISE trials that compared EGDT with "the standard care". All of them eventually came to the same conclusion: Standard Care is as good as EGDT! So lets see what the modern sepsis bundle looks like:


EGDT is a concept, don't use it like a mandatory protocol!


                         
Pic Courtesy : http://shirtoid.com/13876/sepsis/

With full credit to Rivers for coming up with EGDT in 2001 and actually sensitising us about the importance of early resuscitation of these critically ill patients (Fluids/Abx/Pressors). Now, we have realised that, may be we are being too invasive, too many lines and tubes does not sound like a good idea anymore.


May be we need to use the "teaching" analogy here, where LESS IS CONSIDERED AS MORE.

So this is what Modern Sepsis Care Bundle looks like:


  1. Recognise Early and be aggressive
  2. Early IV Fluids 
  3. Early and Appropriate Abx
  4. Early Pressors (NorEpi, Add Dobut if ECHO shows a lousy heart)
  5. Early Source Control
  6. Check lactate and repeat to see how you are doing
  7. ICU/Supportive Care

Lets go through each one of this:

1) Recognise Early and be aggressive

Early recognition is the key. We do not have a foolproof method of recognising sepsis, SIRS too has limitations. Eventually only 26% are found to be in sepsis who come in SIRS and we need to understand SIRS is not infallible, it misses about 1 in 8 with an underlying source of infection. If you are convinced that they are septic, be aggressive with them.


2) Early IV Fluids 

Crystalloids or Plasmalyte can be used as the resus fluid of choice for these patients. Too much NS causes hyperchloremic acidosis/renal injury. Plasmalyte is more physiological. And, 30cc/Kg is not the limit for everyone. Use IVC/Lung USG/ECHO to gauge fluids in septic patients.
3) Early and Appropriate Abx
 Early and appropriate antibiotics are important. I want to emphasise the word "appropriate". The Abx should be administered keeping in mind the common bugs causing that particular infection. Therefore, EARLY and APPROPRIATE, and not just any Abx. They key with Antibiotics is Hit them hard and then deescalate if needed. Each hour of delay in antimicrobial administration over the ensuing 6 hrs is associated with an average decrease in survival of 7.6%. Bottom-line is give them Antibiotics ASAP. 

4) Early Pressors

Norepi is the go to pressor for septic shock. Some also recommend to start it early, along with the IVF bolus. Add Dobutamine to norepi, if you see a poorly contracting heart on the ECHO. In case of refractory shock, add Vasopressin to norepi preceded by supplemental IV steroids. Give them a hydrocortisone 100mg before putting them on a second vasopressor.

5) Early Source Control


If there is a septic source that can be removed, then that is the priority. Plan ahead with your surgical colleagues (ex Necrotising Fascitis, Fournier's, Intraabd septic focus). Get them involved early and get rid of the septic focus. There is no point in giving Fluids/Abx/Pressors even you are not doing anything about the focus of infection.


6) Check lactate and repeat to see how you are doing

You need to check your performance, get a STAT lactate for them on arrival and repeat once you have given them fluids/Abx/Pressors. You are doing good if lactate is getting down.

7) ICU care - Give them some time + supportive care.



And what about CVP and ScVO2?


CVP: Checking CVP gets too invasive for everyone. Sometimes they don't look that toxic when they are normotensive with a slightly elevated lactate. So I try to get away with an EJV catheter for pressors. If they look really sick, I go head and place the CVC and when I place a CVC I check the CVP as well, though I am not a big fan of CVP (Use CVP values like a trend without relying on single values, if you still believe on CVP!)


ScVO2: If you have USG available, you don't really need ScVO2 before you start Dobutamine. Get rid of it. Too invasive, Instead use lactate.


And now, Getting a CVP and SCVO2 are both optional based on the clinician's discretion as per a recent statement made by Surviving Sepsis Campaign. 


Rigid sepsis protocols, that mandates central venous access based only on the lab parameters (lactate, creatinine, platelets, P/F Ratio) regardless of the clinical appearance of the patient needs to be updated. These algorithms and protocols should be flexible, also incorporating a physician's clinical acumen and gestalt. 


Key Points on Sepsis:

  1. Catch them early, give them Fluids, Abx, Pressors (Be aggressive)
  2. Check/Recheck lactate, Control source --> ICU
  3. Don't chase those numbers (8-12, >70%, >65mmHg)
  4. Use EGDT as a concept, not a protocol.

Further Reding:

http://pulmccm.org/main/2014/review-articles/resuscitation-fluids-in-critical-illness-review-nejm/
http://www.scancrit.com/2015/03/21/egdt-dead-long-live-egdt/
http://www.nejm.org/doi/full/10.1056/NEJMoa1415236
http://stemlynsblog.org/surviving-sepsis-update/
http://www.ncbi.nlm.nih.gov/pubmed/16625125
http://www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf

Monday, April 6, 2015

Effective Feedback: The Heart of Medical Education!

This week, lets talk about FEEDBACK. This is something which we should do everyday, may be after every shift or may be twice/thrice on a single shift. An effective feedback can really transform learners. This is important for the attendings /consultants as well as the residents as they need to provide constant feedback to the residents/ medical students. 

So, What is feedback?
Feed- back is an essential element of medical educational that can help students/residents to reach the best of their potential. It enables the learner to achieve goals by reinforcing good performance and providing the basis for remediation whenever required. Feedback, therefore, drives learning and progress and is essential in allowing a student to remain on course in reaching a goal. Its also a good spot where learners can pause and reflect back on their own performance. 


Adult learners welcome feedback, especially when it is based on their performance and tailored to their goals.


Providing feedback is an art which can be acquired overtime with practise. Often this is ignored in medical education and teachers/ instructors are not taught on "how to provide an effective feedback". This is a really critical component and it should be a part of our training. If feedback is not provided, then poor performance will remain uncorrected which while eventually get passed on to the next generation of learners!

The Goals of Feedback:
• Encourage learners to self reflect and think how they might improve 
• To narrow down the gap between actual and desired performance 
Lead to changes in the learner’s thinking, behaviour, and performance 

Note: Feedback is not given to make someone feel good, but for them to reflect back and improve their performance.  It is intended to change behaviour, rather than being an estimate of the students’ worth.


Characteristics of Constructive Effective Feedback 
  1. Timely 
  2. Specific 
  3. Non Judgemental
  4. Non Threatening 
  5. Constructive 
  6. Measurable 
  7. With opportunity to respond 
  8. Motivating
  9. Clear summary and follow up
  10. Conclude with an action plan

Often we hear feedback like "Good Job" - "Keep it up" - "Well Done" which is essentially meaning less. Feedback should be very specific mentioning about what went well and what could have been done better. So don't just say "Good job" next time - Be specific. As educators we also might find it difficult to provide negative feedback. A good way to do that is:

The Approach to Providing ‘Negative’ Feedback 
  • Goal is improvement – ALWAYS 
  • Relaxed environment
  • Let the learner self-evaluate first (You will be surprised to know that how critical they can get about themselves) 
  • Offer positive feedback, too – focus on the work, not the person
  • Offer specific ways to improve
  • Also you can ask for feedback from them on how you can improve as an educator

When feedback fails, it is because the process was handled poorly, causing defensiveness and embarrassment to the learner and leaving them feeling demoralised and rejected. Therefore, Attending training programmes on how to give feedback should be essential for those who teach in medicine because, in trying to give feedback, we still make remarks that have the potential to undermine the learner’s confidence completely.

Methods of Providing Feedback 
  1. FAST – frequent, appropriate, specific, timely 
  2. W3 – what went well, what didn’t go well, what could you work on 
  3. ARCH – ask, reinforce positives, correct negatives, help move forward 
  4. 360 approach – seek feedback from all team members (nurses, pharmacists, patients, etc.) 
  5. Feedback Sandwich – positive → negative → positive 
  6. One minute preceptor – have the learner commit to a plan, have the learner provide support/evidence for their plan, discuss general rules applied to this plan and future plans, reinforce what was done well, provide constructive feedback on areas in need of improvement, identify learning steps 
  7. PendeltonPendleton’s rules are structured in such a way that the positives are highlighted first, in order to create a safe environment.Therefore the learner identifies the positives first. This is followed by the facilitator or group reinforcing these positives and discussing skills to achieve them. “What could be done differently?” is then suggested, first by the learner and then by the person or group giving feedback. 


 What you should never do while providing feedback! Never!
  • Don’t form opinions based on what you’ve heard 
  • Don’t compare to other students 
  • Don’t focus only on the ‘negative’ 
  • Never be sarcastic 

Don't say things like: that was awful, you are stubborn/narrow minded, I will take you for a task next time if you repeat this, better do it right next time, Are you a real doctor or a quack?

It makes me really sad and upset when I hear such comments. Residents and medical students frequently receive feedback that leaves them feeling bruised, depressed and lacking in self-worth. It is not surprising then, that medical teachers brought up in this environment, avoid giving feedback – especially if it is ‘corrective’.

Providing Feedback to the Millennial Learner (born ~1981-2000) 
  • Millennial learners expect to be entertained while being educated - 
  • Despite the incorporation of technology into most aspects of their lives, they actually prefer face-to-face or written feedback 
  • They prefer private feedback 
  • They seek immediate feedback, both positive and negative 
  • Millennial learners assume positive if no feedback given 
Key Points 
  • Feedback is about communication. The key skills are to listen and ask, not to tell and provide solutions. Be specific, be clear.
  • Learn this with practise - See which method works out for you.
  • Most important: Always Be sensitive and be NICE!

Further Reading: