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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, August 29, 2016

Budding EM

EM is still a budding field in India and I see many of our non-EM colleagues (who have never even worked in an ED) lecture during EM summits. While there is no doubt about their subject specific knowledge, there is often a disconnect felt when they try and teach EM or Critical Care. So this was one of the poll created recently:

Q - Should we be inviting non-EM physicians at EM conferences to lecture about Emergency Medicine?


  1. Yes - 62%
  2. No - 30%
  3. Yes, but only after they go thru an EM induction program - 8%


My thoughts on this..




Some more thoughts from the FOAMed world:

Steve Carroll I think non-EM specialists certainly have something to offer when it comes to their specialty and how they would manage something or what they prefer that we do in the ED- but, for example, if a trauma surgeon wants to tell me how to do airway management (with the exception of a trach) then they should immediately close their mouth because they think they know what they are talking about but in reality they have no idea...

Justin Hensley Different specialties can offer some interesting perspectives. You have to watch what they're going to say though, because sometimes they're too specialty oriented.
Justin Hensley More like, asking the stick manufacturer to comment on ice hockey. They might not play the game, but they can offer insight to the tools.
Justin Hensley We do a feature called "ask the expert" where we bring in other people and them ask them EM specific questions. Makes it a bit more emergency oriented.

MC Gill One who never worked ER will not add any value. It is like asking a cricket player to give opinion about ice hockey.

Bishan Rajapakse Great question Lakshay (and interesting results and discussion that is emergency from the question) - I guess it all depends on which non-EM people you ask. EM is not an island, and to develop, even in mature systems, requires interdisciplinary action - especially policy makers, public health, pre-hospital, nursing, allied health, health minister etc. Even having different specialities attend EM can be very helpful - after all, we work in integrated hospitals. ------------------------------My experience of attending different IEM conferences since 2007 is that I think it is quite advantageous to have multidisciplinary conferences. A well facilitated forum with multiple disciplines is usually very productive. For example, I recently attended a high profile social media and critical care conference in Dublin, which was a true international collaboration, and interdisciplinary collaboration (doctors, nurses, paramedics, and even surgeons, and social workers were plenary speakers) - the results were good. There was an productive IEM track where people from all backgrounds were sharing ideas.-------------------------------- MC Gill I can hear your frustrations. I remember at one of the early conference hearing the question from an ex-president of college of physicians which went something like "so what is the difference between an intensivist and and emergency physician exactly?" - but I think this was a great question and great opportunity to educate those who still don't know what EM is all about - after all we are one of the most dynamic specialities that exist and it is important to keep others in the loop if we are to progress sustainably. Justin Hensley - i agree offering insight in ways that may cover our own blind spots. If people are invited and discussion is facilitated appropriately they will only offer benefit, and useful discussion. --------------------------------The key in my opinion is good facilitation at conferences, which is sometimes lacking. Using newer mediums such as twitter allow for a range of discussion to occur from the delegates, rather than just the loudest most prominent people in the room.

Praveen Chenna Invite .
They can lecture on their subject n it's importance or relevance to the field of emergency , is always acceptable.


Hashmat Faheem Emergency Medicine is comparatively newer branch as a speciality in India.. Protocols, Diseases generally varies from places where speciality is established... it might be useful to get some inputs from Non Emergency Medicine Faculties


of course we should... But they should invite EPs to speak at their conferences too

Yeah, we work in teams (PH, EM, CC, Anesth, surg, etc) so I don’t see why not. Just need to have good communication


Feel free to share your comments.


Author:

              
     Lakshay Chanana

     @EMDidactic
                                                        






Monday, August 22, 2016

CLINICAL HANDOVER: from “Me” to “You”


In a busy emergency department, there are days when all the beds are occupied by patients and your emergency gates are flooded with incoming patients; your duty is about to start and the scenario is overwhelming. You are anxious to know every essential detail of each patient before you take over the responsibility. Clinical handovers are an important responsibility of every Emergency Physician. Handovers can range from ED physician to ED physician during shift change, ambulance doctor to ED physician, ED physician to an intensivist during patient transfer. ED physician should be well versed with giving as well as receiving a thorough, concise, handover for benefit of patient, hospital and self.
A clinical handover is defined as ‘the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis.’ (1)
A good handover forms essence for continuity of patient care. It involves effective communication, clinical documentation, transfer and referral notes and discharge documentation. In India, clinical handover is one of the least researched topics; more so, there is no defined pattern or checklist that is used by doctors while giving handover.


STATISTICS
Medical errors are the third leading cause of death after heart diseases and cancer in the USA. Communication errors form major cause of up to 70% of sentinel events, out of which 62% major factor was change in shift. There are multiple parts of a handover where important information may be dropped or not conveyed. This can affect patient care, length of stay, and department flow.
A survey carried out by Kessler et al among 41% of ACGME accredited EM residency program; 56.6% of EM physicians responded that they do not use standardized handoff.\


STRATEGIES
In the USA, handovers are in the form of sign-outs. The format used for sign outs could be verbal, written or digital. One of the sign-out strategies used is called ANTICipate. It consisted of

  • Administrative data (Name, age, sex, bed no, admission status);
  • New Information (chief complaints, brief history, differentials, medications, allergies, current baseline status, recent significant events/procedures);
  • Tasks (what needs to be done, if-then approach);
  • Illness (How sick is the patient/ triage category);
  • Contingency plan (what may go wrong/ what to do about it, what has/has not worked before, difficult family/ psychosocial situation)

The Joint Commission in 2006 introduced a standardized approach to handover: the SBAR method (3). The SBAR approach consists of situation, background, assessment and recommendation. Only the most relevant data is included and put together in SBAR frame and presented effectively to the incoming team who is also well versed with the approach. Then, specific questions may be asked to clarify and confirm the handover. SBAR is generalized and can be used for all kinds of patients. This should be followed by ‘read back’ or ‘repeat back’. In ‘read back’, the receiving team repeats the important information, so there is a closed loop communication.

Example:

  • Situation: Mr. Kapoor has fever with chills and petechial rash.
  • Background: His symptoms started 3 days back. His temperature is 102, heart rate of 100/min and BP 130/80. He has no co-morbidities. His platelet count is 1lakh. Now, he has generalized weakness.
  • Assessment: My assessment of the situation is he has acute febrile illness most likely dengue.
  • Recommendation: I recommend we hydrate him well, bring down his fever, trace the Dengue report and keep watch on his platelet count and admit him on floors under Dr. ABC.

A specific handover technique for trauma patients is IMIST-AMBO. IMIST-AMBO stands for


  • Identification/Introduction,
  • Mechanism of Injury/Medical complaint,
  • Injuries/Information related to the complaint,
  • Signs and Symptoms,
  • Treatment given/Trends noted,
  • Allergies,
  • Medications,
  • Background history and
  • Other information.


COMMANDMENTS FOR A GOOD HANDOVER
There must be a crossover of two shifts. Adequate dedicated time must be allowed for handover. Handover must be given as a team, consisting of team leader, junior doctors and nursing staff, so everyone is on same page and clarifications can be done, if needed.

Sufficient and relevant information should be exchanged to ensure patient safety so that the senior doctors have knowledge of the triage category 1 and 2 patients; junior doctors of the team are adequately briefed on concerns from previous shifts and tasks not yet completed are clearly understood by the incoming team.


GOOD HANDOVER BENEFITS PATIENTS
It decreases morbidity and mortality of patients because of greater continuity of care. Patients don’t like repeating the history again and again to each health care provider. A good handover prevents repetition, improves patient satisfaction. Patient’s perception of professionalism is reaffirmed and improved.


GOOD HANDOVER BENEFITS DOCTORS
Professional protection: Clear and accountable communication can protect against wrongful attribution of responsibility for errors that occur.

Reduction of stress: feeling informed and having up to date information enables doctors to feel more confident in patient’s care. Doctors have found that handover can be a useful experience that gives them the opportunity to involve appropriate specialties early, for example intensive care. There is ability to discuss cases with other specialties in an open environment.

Educational: handover provides development and practice of communication skills and a well-led handover session provides a useful setting for clinical education

Job satisfaction: providing the best possible quality of care is highly rewarding and is fundamental to a doctor’s sense of job satisfaction

DIFFICULTIES/SHORTCOMINGS
In a busy ED, there could be lots of disturbances, interruptions and distractions that can prevent a good handover. Handover should have dedicated time except for life-threatening emergencies.

Not everybody is well versed with a common handover scheme. Each hospital should develop their own handover checklist and have role plays to make a conscious effort in reducing errors and delays.

Handover should be carried out as team instead of hierarchical handovers (ie junior doctors to junior doctors and so on). Team debriefing helps in better patient care, prevents delays and minimizes errors. It also makes handovers- a teaching tool.

Take Home Points  
  • Use a checklist like SBAR for transferring information from one team to other along with ‘read back’.
  • Handovers as team can have better continuity of care.
  • Simulate handover technique to become well versed at it.  
  • Use the dedicated handover time as a teaching tool.


References
  1. National Patient Safety Agency, London. As cited in Safe Handover: safe patients. British Medical Association, London, pg 7.
  2. Fassett, R G & Bollipo, S J. Morning report: an Australian experience. Medical Journal of Australia 2006; 184: 159-161.
  3. Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care 2010;19:493–7
  4. Sujan, Mark, et al. "Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research." (2014).
  5. Kessler C, Shakeel F, Hern HG, Jones JS, Comes J, Kulstad C, Gallahue FA, Burns BD, Knapp BJ, Gang M, Davenport M. An algorithm for transition of care in the emergency department. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine. 2013 Jun;20(6):605.
  6. Kessler C, Shakeel F, Hern HG, Jones JS, Comes J, Kulstad C, Gallahue FA, Burns BD, Knapp BJ, Gang M, Davenport M. A survey of handoff practices in emergency medicine. American Journal of Medical Quality. 2014 Sep 1;29(5):408-14.
  7. Hern H, Gallahue FE, Burns BD, Druck J, Jones J, Kessler C, Knapp B, Williams S. Handoff Practices in Emergency Medicine: Are We Making Progress?. Academic Emergency Medicine. 2016 Jan 1.
  8. Stokowski LA. Who Believes That Medical Error Is the Third Leading Cause of Hospital Deaths?. Medscape, May. 2016 May 26;26.
  9. WHO Collaborating Centre for Patient Safety Solutions. Communication during patient hand-overs. Patient Safety Solutions. 2007; 1:solution 3.
  10. Committee on the Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2004:45.
  11. Committee on the Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000:36.


Nikhil N. Tambe - @nikhil16mar
M.B.B.S., ECFMG (USA)


Emergency Medicine Resident (PGY-2)
Masters in Emergency Medicine (GWU)
Kokilaben Dhirubhai Ambani Hospital, Mumbai
Instructor (American Heart Association)
Lifesupporters Institute of Health Sciences, Mumbai


Monday, August 15, 2016

MRCEM part C: 9 unsolicited advices!


1.    Practice is the mantra!
For part C, the formula is simpler than B. The more you practice stations, more the chances of passing the exam with ease.



2.    Find someone or be found by someone (who has cleared part C) who can monitor your practice sessions and give corrective feedbacks each time.
Plan the practice sessions well in advance so that you don’t mix it up with part B preparation and mess up both.




3.    Be the Bond, James Bond!
Develop a unique opening line for introduction in every station. NEVER fumble in introduction or conclusion! Also, clean hands save lives!



4.    Form a group for the practice
Decide what a group is, what a crowd is and what a mob is! Be careful!
Stress on things that you don’t do often – Psychiatric assessments, systematic joint examinations, etc.
Some unforgettable fun moments during the practice sessions are guaranteed!



5.    YouTube is your best friend – Like always!
This is extremely useful. This channel called ‘geekymedics’ on YouTube is a goldmine.  These videos are very well structured and almost cover everything that you need to perform in an OSCE. 



The following links might be very useful for different sections of part C

1.Geeky medics (All examination and procedural skills): https://www.youtube.com/user/geekymedics123
3.Ottawa knee rule – Application demo with explanation: https://www.youtube.com/watch?v=sPMmIptAs-w
4.Ottawa ankle rule – Application demo and explanation https://www.youtube.com/watch?v=Dqq09sR0vuc
6.Latest ACLS update has a very good video about breaking bad news
7.Psychiatric history taking by University of Nottingham: https://www.youtube.com/watch?v=4YhpWZCdiZc (these videos are longer than 7 mins. So you need to create a tailored down version of yourself once you see these videos)

6.    What books?
Though the main focus should be on practice some books help you to get an idea about the checklist. Though these are not standard checklists and may vary from the actual checklists in the exam, having an overall idea is not bad, isn’t it?
‘125/110 OSCEs’ and ‘Mastering emergency medicine’ can be very helpful in this regard.




7.    Reaching a specific diagnosis might not be always very important but being logical, empathetic and structured in your approach is. So if you are Donald Trump, you will never pass the exam (Oops!). Always explain the plan to the patient and ask if they have any further questions or concerns!  Another very important aspect is always maintaining a non-confrontational attitude towards the patient! Patient has 5 global marks with him. Be nice and he’ll be nice to you!


8.    Read the pie chart: Before you enter every station, know where the focus is! There’s no point taking history for 6 minutes when the history is only 25% of the pie chart and the rest is examination!


                    
9.    Difficult stations!
Difficult stations are usually difficult for everyone. You need to pass just 14 out of 18 stations. So, do the basics very well, do not lose confidence and think what you would do in the ED if you encounter a patient like that, conclude well, thank the patient!



The most crucial aspect in passing MRCEM is time!

-       Manage time during your preparation – Prepare a study schedule for the entire month covering all the topics – For B and C.
-       Time your sessions while practicing for part C. Each station lasting up to 6-7 mins(use a stopwatch)
-       Maintain strict timing in all the mock sessions of part B.
-       Reduce the time you take for answering each question!
-       Always be aware of the time you spend on each question in the exam
-       Writing using a pencil consumes more time compared to pen – So practice writing with a pencil! Also, pencils can break!
-       Be very cautious of time in stations which expects you to do multiple things at once – Ex: Teaching, examining, taking history and explaining the plan to patient.




             TIME IS LIFE!  YOUR TIME STARTS NOW!




       
Author
Dr. Apoorva Chandra, MRCEM
Twitter: @apoorvamagic  

Resident, Emergency Medicine         
Apollo Health City, Hyderabad                                                         



apoorvamagic@gmail.com