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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, May 25, 2015

Demystifying ED Consultations!!

One of the most crucial things that we do everyday at work is “asking for a consult/referral”. ED Consultations can be really difficult at times revolving around self-respect – diverse values – bonding - interests and interpersonal relationships. But “How to ask for a consult” is something that is rarely taught to EM residents, at least I was never taught this as a junior trainee in EM. Lets find out what’s the best way to get a consultation:

As Emergency Physicians deal with multiple other subspecialists, 24X7. It is our responsibility to take care of the sickest and simultaneously pass on the information and arrange for definitive care. To do this, we must have a thorough subject knowledge about General Emergency Medicine and also the competency to pass the information appropriately. There is not much of literature out there on this particular topic. Trainees screw up time and again; learning this skill gradually with their own goof ups gauging them as per the requirements of various consultants.

Whether this info is passed on to the specialty consultants/Attendings or Specialty Registrars/Residents depends on the institutional protocols. Here we are going to set some general rules that should probably work for everyone.

1)    Why/ When do you need a consult – Lead with a headline
You must have a succinct idea about this – Clarify the purpose and urgency of your consult. Do not start your medical school kind of presentation with a detailed history. They are too busy for that. Cut it short and come to the point ASAP, have your thoughts organized and the data that supports your thinking. Don’t ask for a consult just because the consultant is available; ask for it only if it is required.

2)    Gather your ingredients
Get all the data with you before you call them – history – old blood reports – meds – previous procedures - imaging etc. Another way of doing this is, by thinking, if you were in their shoes, then “what would you want”? When you do your rotations with them, understand their perspective to smoothen your consultations when you get back to the ED.

For instance - Few important specialty-specific questions that they love to know are:
(Note: This by no means is a complete list)

·      Neurosurgery: GCS, Na, Pupillary Response
·      Cardiology: ECG, Troponin, Previous Stress tests
·      Nephrology: Urine Output, K, Urea/Creat
·      OGYN: GPLA, LMP

And if you don't have an answer to something – never cook up a story or numbers – Be blunt and let them know that you DON’T KNOW.

3)    Negotiate
Whenever there is a difference of opinion, try to negotiate and settle down the differences. For instance, if the neuro consultant is too busy for a suspected epidural abscess and wants ED to get some sort of imaging first, ask him to send at least someone from neurology services (may be a resident/registrar) to evaluate the patient as you arrange for the imaging.

4)    Be Nice
Don't have a prejudice and avoid judging them if you have had a bad experience with them. Anyone will get upset if you call and tell them to come to the ED right away – This is human nature. Be nice and soft, but never compromise patient care.

All this can be summarized in the “5C” model of consultation:

5C Model

ü  Contact - Introduction of consulting and consultant physicians. Building of relationship.
ü  Communicate - Give a concise story (30-60seconds) and ask focused questions. DONT START MEDICAL SCHOOL CASE PRESENTATION – They don't have the time for that.
ü  Core Question - Have a specific question or request of the consultant. Decide on reasonable timeframe for consultation. Come to the point ASAP.
ü  Collaboration - A result of the discussion between the emergency physician and the consultant, including any alteration of management – BARGAIN/ NEGOTIATE.
ü  Closing the Loop- Tell them what is the plan and whatever you understood

Document your conversation (better to record all telephonic conversations)

+ Don't forget the kindergarten basics

Ø  Greet & Introduce yourself
Ø  Confirm their name (Occasionally, some of them might get upset if you ask their name!)
Ø  Permission: Do you have a moment to discuss a case?
Ø  Be confident and pleasant
Ø  Listen to them and show respect for their opinion
Ø  Thank them
Ø  Also, practice a few times with your supervisor before you actually call them

Difficult Consults:
We all have seen nasty consultants who come to the ED and start throwing things around. 
Consultants are like "guests in your house". Treat them the way you treat your guests. This is going to turn things in your favour often getting them to do stuff you wanted to be done (procedure, admission etc.)

Use Key phrases: Often required to make people feel valued:

Ø  We need your expertise/help….
Ø  Your opinion is really going to make a difference….
Ø  I am concerned because….
Ø  I think this is best for the patient….
Ø  I would really appreciate if you could come down and see him once.…
Ø  I know you guys are really busy abut I cannot miss this diagnosis….
Ø  I don't want to waste your time but no one else can do it….
Ø  I know, It was a really busy day for you – but I need your help..

If nothing is working to get them down to the ED, Remember:

  • Not to raise your Voice or Swear – Bad for you and for the patient as well
  • Don’t threaten them

Occasionally, despite doing your best, things are not going to turn out well. Then, just be polite and tell them you are going to speak to your consultant/supervisor/attending and get back


Tell them respectfully : “This discussion is not going anywhere, I think we both need to think over it and I shall get back in sometime”.

These methods may not always work but definitely provide us with a good framework for asking a consultation from the ED. Factors like your rapport, previous interactions with them also play an important role when you ask for a consultation.

Take Home Points
1)   5 Cs Contact, Communicate, Core Question, Collaborate & Close the loop
2)    Never raise your voice or swear at them
3)    Don't forget the Kindergarten Basics
4)    Know the key statements to get them down!


For further reading:
  1. Salerno, Stephen M., et al. "Principles of effective consultation: an update for the 21st-century consultant." Archives of internal medicine 167.3 (2007): 271-275.
  2. Kessler, Chad S., et al. "A prospective, randomized, controlled study demonstrating a novel, effective model of transfer of care between physicians: the 5 Cs of consultation." Academic Emergency Medicine 19.8 (2012): 968-974.
  3. EMRAP - Feb 2011 Episode Summary
  4. EMRAP - Sep 2013 Episode Summary
  5. http://shortcoatsinem.blogspot.com.au/2012/10/sweating-bullets-and-killing-em-with.html?spref=tw
  6. http://lifeinthefastlane.com/referring-patients-from-the-emergency-department/

Monday, May 18, 2015

Airway Pearls from the CRASH Airway Course - Part 2

We are going to continuing with the Airway Pearls this week:
If you have not seen the last week's post on Airway Pearls, go through it first.

4 big airways pearls for this week are:

1) Positioning - Head lift 

I have emphasised enough about this last week with "horizontal ear to sternal notch" and "ramped up" position. If you are still don't get an optimal view despite doing these manoeuvres, one last thing which might help you before you move to your plan B is a "head lift" to visualize the cords. Here, with the tip of the laryngoscope blade sitting in the vallecula, you keep your right hand under the occiput and flex/extend the head. When you get an optimal view, fix the head at the same spot by supporting with an extra set of sheets.(see the image below)

    Head lift with your right hand to get an optimal view of the cords (Always use full PPE)
This is what I do to get an optimal view, 

1) Ear to Sternal Notch
2) Ramped up positioning
3) External Laryngeal Manipulation
4) Head Lift

and Move to plan B - if none of these work.

2) Make some space for yourself

When I was learning airway, there were many occasions when I got a chance to intubate and I failed to even insert the scope inside the mouth. And then my registrars/attendings/consultants used to come - do the procedure without a hitch and move on. I used to feel really embarrassed everytime this happened untill I realised that in some patients, with a huge chest wall or morbid obesity, it gets really difficult to insert the scope inside the mouth to start with. 

The best thing to do with them is, inserting the scope like we insert the Oropharyngeal Airway (see image "a" below), and once you enter inside the oral cavity, turn 90 degrees anticlockwise that brings you in the required position.(image b)

a - Inserting the scope in OPA manner and turning 
it in 90 degree anticlockwise direction
b- Scope position after 90 degrees anticlockwise rotation  
Another common issue is, not finding enough space to get the scope inside due to restricted mouth opening or a large tongue. This can be addressed by asking your assistant to pull the cheek on one side while you are inserting the laryngoscope inside the oral cavity. (see the image below)

                                                Asking your assistant to pull the cheek to the side
3) The ET Tube

A major pitfall while inserting the tube is, when we try and go straight into the mouth after visualising the cords. This blocks our own view of the cords and can lead to misplacement of the tube. This can be fixed by entering the mouth from the right side as depicted in the  image below. 
Trying to insert the tube "straight - in" & blocking your own
view of the cords (Wrong)
Inserting the tube from the right side, not
interfering with the view   (Right)                  
4) Bougie is your best friend!

Bougie must be available for every airway. Keep it in your airway kit - right next to you before taking the first attempt rather than asking for it after you have failed.

I have witnessed quite a few times "oesophageal intubations" with the bougie which makes no sense. The key points when using a bougie are:
  • Keeping the scope inside the mouth even after passing the bougie in - until you rail road the tube over the bougie. DO NOT TAKE THE SCOPE OUT and try to jam the bougie inside!
  • Learn how to differentiate between trachea and oesophagus with the bougie: Keep advancing the bougie inside gently and feel for the tracheal clicks --> If you hit the carina OR feel the tracheal clicks as you advance the bougie, then you are in the trachea. In contrast,  if don't feel any clicks or resistance and are able to advance the bougie almost completely inside, then you are in the GI tract.
Note: Be extremely gentle while advancing the bougie inside to avoid traumatising the airway.

Hope this was useful..Thanks!

Special note of thanks to Dr. Azhar and the authorities of Simulation Lab, Apollo Health City, Hyderabad

Monday, May 11, 2015

Airway Pearls from The CRASH Airway Course - Part 1

I was lucky enough to show up at the CRASH Airway Workshop at The Crashing Patient Conference by the Airway Guru "Ken Butler" at The University of Maryland, Baltimore held in October 2014. It was an amazing trip where I got an opportunity to meet some great people. 

Today, I am going to share three big "Airway Pearls" that I learned form the course:
1. Positioning is the key (often ignored in the ED):

For every ED Airway - Make sure that the Ear and Sternal Notch are in the same horizontal plane when you position the patient. To achieve this, you need to support the occiput with some sheets OR in obese you may need to elevate the head end (ramped up position - Reverse Trendelenberg position) and support the occiput as well as the shoulders. Bottom line is take a look from the side to bring EAR and STERNAL NOTCH in the same horizontal plane.

Ear --> Sternal Notch
Ramped up position can be achieved this way in trauma
when you can't mobilise the neck

This position maximizes the upper airway patency and improves the mechanics of ventilation. In morbidly obese this position also lengthens the apneic time period to critical hypoxia + shortens the time needed with BMV to return back to normal oxygen saturation.

2. Apneic Oxygenation OR Nasal Oxygen during efforts securing a tube  (NODESAT)

Apnoeic oxygenation is the application of high flow oxygen via nasal prongs at 10-15L/minute during intubation (during laryngoscopy!). Keep the O2 flow at 4L/min to start with and once you push the induction agent, go upto 15L/min. Continue to provide O2 via nasal prongs  until you pass the tube inside. With this, you will be blowing some oxygen into the lungs, that will diffuse into the bloodstream (it works because even when they are paralysed, blood is still flowing in their body), and buys you some time before the sats start to  drop (extends your safe apnea time). And 30 more seconds of safe apnea time is a lot during the heat of resuscitation. In adddition, again this also shortens the time needed with BMV to return to normal oxygen saturation. 

Apneic Oxygenation

Some high risk groups for desaturation are Obese, Paediatrics, Pregnant and those with a lung pathology. 

One of my anecdotes with apneic oxygenation, Recently I remember bagging a sick hypoxic patient to get the sats up, the maximum I could reach was 97% but then with apneic oxygenation I witnessed the sats going from 97-->100% during laryngoscopy!! 

So make it a part of your Intubation checklist and use it for every ED intubation.

3. Bimanual Laryngoscopy (Using both your hands during the procedure)
This one is my favourite. When we use both our hands during laryngoscopy, that gives a great view without applying too much force. Lets see how it is done:

Bimanual Laryngoscopy (This image in only for demonstration purpose, Always use full PPE)

With scope in your left hand, enter inside the mouth and move in, step by step and the first structure to be visualised is the epiglottis (epiglottoscopy), following which the tip of the blade should be placed in the valeculla (Don't go too far). Now, with your right hand optimise the view using ELM (External Laryngeal Manipulation), once you get an optimal view, take off your hand and ask your assistant to maintain the pressure 


To start with, ask you assistant place his hand over the larynx and give pressure on top of your assistant's hand to get an optimal view (see the image below). This keeps the pressure exactly at the same spot. Bimanual Laryngoscopy dramatically improves the view of the cords.

Bimanual Laryngoscopy with an assistant to start with 
(This image in only for demonstration purpose, always use your full PPE)

Stay tuned.. I will be back next week with Airway Pearls - Part 2


One game changer paper on Airway, that is worth reading is:
Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management Ann Emerg Med. 2012 Mar;59(3):165-75.

Special note of thanks to Dr. Azhar and the authorities of Simulation Lab, Apollo Health City, Hyderabad