Why do Emergency Medicine

Why do Emergency Medicine?

Listen from the inspirational team of emergency healthcare providers in Edinburgh. 

For more, checkout EdinburghEM website 

Initially published by RCEM youtube channel - 21/01/2016

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

MedReach Courses

MedReach is an online video-learning platform for health professionals with two broad aims:

1. To provide fair and equal access to world-leading medical education for all health care professionals;
2. To improve healthcare learning and delivery in low-income countries.

Access to high-quality learning is currently limited by time, funding and geographic location with those in remoter communities and low-income countries the most disadvantaged. MedReach aims to overcome these barriers by filming high-impact courses and conferences, and providing online access at a time, pace and location that suits the user. We charge a modest amount to those that can afford it (high-income countries) and give it all for free to health-professionals in low-income countries, as well as donating a significant portion of sales to healthcare projects in poorly resourced areas.

So, learn from ‘world-experts’, take notes, export course certificates and summaries of learning, and at the same time contribute to healthcare improvement in areas that need support.

We often hear about educational courses, but travelling to another country and the heavy costs involved to attend an 6-8hr course is always a setback.  Having done a few of MedReach courses personally, this is something I highly recommend for Emergency Medicine and other acute care specialities trainees. Watching eminent educators such as Rich Levitan and Arun Sayal and learning from them at our own pace and comfort is a joy. To begin with, I was a bit skeptical about learning skills requiring some dexterity with a video-based course but achieving finesse is certainly possible if your basics are set right. 

Do check out https://www.medreach.org/courses/ for more information. 

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

Prep for DNB Emergency Medicine (India) - by Manasa Seshadri

I cleared my DNB EM Practical Exam and with that, I have successfully completed my Post Graduation in Emergency Medicine. 

If you are pursuing the emergency medicine course in a hospital with inadequate/ negligent bedside training and academics or have faced discrimination and / or oppression while working in your department, I will tell you straight away that YOU ARE NOT READY to face the practical exam conducted by NBE and you have to gear up, right now. Most of you are likely to belong to the above mentioned group, given the current political debacle and bureaucracy trends in EM in our country, which hopefully will change in years to come. That topic, for another day, another time. Now, only about the preparation for the practicals.

I was sure as hell not adequately prepared for the exam. If given 3 months from now to prepare and give the exam again, I still won’t be adequately prepared. Most of what I am writing here is from the understanding I gathered after the exam and not before! Even saying that loud sounds scary to me, but it’s true!

First things first, the DNB EM practicals is a 2 day marathon. It is quite a lot. So grab an energy drink. The guidelines for conduction of the practical exam are sincerely followed in all centres where the exam is conducted. The order (cases, spotters, OSCE, viva) may get shuffled, however that is not your concern. You have to be prepared for all stations and equally. Like theory, every point you make to the examiner should count.

I.CASES:
You will be given 4 long cases and 4 short cases. You would be given 15 minutes to take history, examine, and format a diagnosis and plan of care for a long case. You will be given 5 minutes to do the same for a short case, however the history and the examination will be limited to the organ / part of body in question.

Long case 25 marks each case – total 100 marks
Short case 10 marks each case – total 40 marks

The viva for the long case will be taken for 15 minutes and the short case for 5 minutes. There was a bell at the end of time and the viva did not exceed this time limit where I gave my exam.
The long cases are one case each in:
a. Medicine
b. Surgery
c. Trauma and Orthopaedics
d. Paediatrics 

You will have to be aware of Medicine, Surgery, Trauma and Ortho, Paediatrics format of examination and know what specific questions to ask in history. This will require you to touch upon basic clinical aspects of these subjects from the respective books other than reading only the standard EM books. I would have written the above sentence in bold, but I don’t want to scare you :p

Understand here that the viva may will not be ABCDE that you are so fond of and familiar with as an Emergency physician, it may not include any part of ABCDE at all depending on your exam centre and your examiner. For example, my long case in Medicine was an acute exacerbation of COPD and LRTI. I was revising the resuscitation algorithms for the same before I was called for viva. 10 out of 15 minutes of my viva was to enlist the indoor and outdoor pathogens causing COPD. Beyond vehicular smoke, cigarettes and kerosene, I was lost. I dug into my memory from MBBS to find more points and my examiner only waited for me to respond and did not ask me anything else. What my examiner wanted to elicit from me was the various ingredients of gober gas that can cause COPD. The longest 10 minutes of my life. Not because the question was tough, but I was not oriented to react to that question in the last 2 years of my training.

Pick up the recent editions of Kundu / Algappan and /or Hutchison and brush up on the basics. Similarly for Surgery- you will have to know examination of let’s say, a chronic venous insufficiency or amoebic liver abscess the way you did when you were preparing for Surgery practicals in MBBS. 

The short cases are one case each in 4 out of the 5 subjects below:
a. Dermatology
b. Ophthalmology
c. Obstetrics & Gynaecology
d. ENT
e. Psychiatry 

As with the long cases, you will have to be aware of an Ophthalmology, ENT, Psychiatry, and OBG format of examination and know what specific questions to ask in history. This will require you to touch upon basic clinical aspects of these subjects from the respective books other than reading only the standard EM books. 

You need to be familiar with using an ophthalmoscope, a nasal speculum, an otoscope. These instruments were just kept on a table outside, and it was upto us to use them as required. So no visual cues of these instruments on the bed to alert you to use them, be warned :p You may be asked to demonstrate the use of these instruments on your patient. So obviously you need to be aware of what normal looks like and what pathology looks like with the use of these instruments.

Summary for case presentation, you have to prepare for the cases (enlisted in the GUIDELINES FOR CONDUCT OF DNB EMERGENCY MEDICINE PRACTICAL EXAMINATION INCLUDING OSCE) both from respective subject clinical books (MBBS clinical reference books would suffice, speciality clinical books on the same are not required) and EM books. I did not do the former, and it was difficult for me to answer the viva.

The EM books that I read for cases were:
• Tintinallis 8th edition
• Emergency Medicine Oral Board Review , 2 nd edition
• MRCEM 125 OSCE

Other books that may help are:
• The RESUSCITATION CRISIS MANUAL Scott D. Weingart David C. Borshoff
• The Atlas of Emergency Medicine by Kevin J Knoop , Lawrence B Stack , Alan B Storrow, R Jason Thurman
• Clinical books used as reference in MBBS

II.OSCE:
It is an objective assessment, so gather all your points here. You say the right thing in the right order and narrate your resuscitation algorithm, you are awarded points. Each right point mentioned, will fetch you a mark and grab them all. It is very doable with repeated revision. These are listed under OSCE stations and called Skill stations in the “GUIDELINES FOR CONDUCT OF DNB EMERGENCY MEDICINE PRACTICAL EXAMINATION INCLUDING OSCE”. Like most of you would have, I had completed BLS, ACLS, ATLS, PALS provider courses and had revised the respective manuals for this station.

Algorithms you need to be prepared for include:
1. BLS (5 marks)
2. ACLS (10 marks) the examiner may take you from a stable patient with stable rhythm to stable tachy to unstable tachy to brady to arrest. Be well versed with drugs and doses, and defib or cardioversion joules. 

3. ATLS (Core case scenario/primary and secondary survey/Helmet removal/Spine board applications/ cervical spine stabilization) (10 marks)

I got a hypothetical polytrauma case with extremity fracture, tension pneumothorax and FAST positive internal bleeding, and had to go through the entire ATLS format.
After that I was asked to demonstrate Helmet removal for another hypothetical case. I thought the question was straight forward and went ahead to remove the helmet according to the protocol, when my examiner interrupted asking me if Primary assessment was not important before I proceeded with the helmet removal. So treat the mannequin as a real patient and do what you would do in real life scenario. These approaches are however subject to the exam centre and your examiner, and you will get familiar with what he/she wants on call.

4. PALS/NALS (10 marks)
Yes, you have to know NALS, as perfectly as you know ACLS. No compensation.

5. Airway (10 marks)
I was given a case scenario by the examiner, and I was required to arrive at the diagnosis (mine was anaphylaxis) and list down the assessment and approach to a difficult airway. This will require you to read an anaesthesia book for the same. Any suitable handbook would do. You need to be familiar with all the assessments of the airway, all the devices used and their indication for use, advantages and disadvantages of each over one another, surgical airways and narration of the surgical procedures for the airway. Watch videos on youtube and familiarise yourself with verbalising the procedures. You may include MRCEM PART C videos as a preparation material for this, but it won’t suffice as a sole source.

6. Surgical skill station (Suturing/Central line insertion/ICD/wound care) (10 marks)
If you are given a suturing scenario, it begins with assessment of the wound, which will include the depth, character of the wound, indication for suturing, wound cleaning, need for prophylactic antibiotic or not, consent, types of suture materials, advise for suture removal, types of sutures, demonstration of suturing technique (you will have to be familiar with atleast a couple of different suturing techniques other than simple interrupted sutures). Whether you will be asked all of this is left to the discretion of the examiner, but your preparation will have to include all this. Watch appropriate videos online for this station as well. You may include MRCEM PART C videos as a preparation material for this, but it won’t suffice as a sole source.

7. Ortho skill station (Hemorrhage control/log roll/splints/pelvic binder) (10 marks)
I was asked to demonstrate application of a pelvic binder , and here again my examiner expected me to go through the primary survey of ATLS , I had to determine a hypothetical pelvic bleed with the ultrasound machine , stabilise vitals with basic resuscitation , and end the examination with the observation that BP had improved a little with the binder placement. To what length he wants to keep the station active and assess you is completely upto the examiner, but never fail to be in your most alert senses to answer the questions and use presence of mind.

Don’t expect to be provided with clues if you are fumbling with order of examination or assessment. The examiner is more likely to keep silent and mark you than help you with clues to move forward.

8. Communication skills (10 marks)
This is one thing that I had prepared for from only one source the MRCEM part C OSCE book, Communication skills chapter. But what you need to know is you can only gather the format of dealing with these situations from the OSCE book, but the actual way of answering an Indian relative/patient in stress can be more beneficial from practicing with friends or seniors.

My scenario was talking to an angry parent whose son had developed complications of dengue on day 3, and had been sent home from ER on day 1.
My job was not just “talking to an angry relative”, but it included arriving at a diagnosis of a probable viral hemorrhagic fever from the history and hypothetical examination, answering about risks of dengue in Indian environment and what I planned to do with the patient further.

Similarly, if your scenario is breaking bad news or death of the patient to the relative and you want to address organ donation with him/ her, you have to be familiar with laws regarding the same in the Indian scenario.

III.SPOTTERS: (4 marks for each spotter, 40 marks total)
A good area to score points, but needs a good amount of preparation.
We had 10 spotters, 2 minutes for each spotter, and 2 questions to be answered for each spotter.
The areas that you need to cover are :
1. USG (image / video)
2. X-ray chest and Ortho related X ray
3. CT brain
4. ECG
5. ABG
6. Clinical photograph

I don’t think there are any standard books for all of these, but you need to read books which teach you basics of how to read an X-ray, how to read a CT scan, how to read an ECG, how to read an ABG to start with. Then, you need to solve these problems from any number of sources online or apps which offer tests for the same. There is no end to prepare for these spotters, do it every day for some time during your preparation.

Some books that may help are:
• ECG made easy
• X ray made easy
• Emergency ultrasound made easy
• Paul Marino ICU book for ABG

Kindly don’t limit yourself to only the above-mentioned books, keep reading anything relevant that you find online.

IV.ULTRASOUND STATION (25 marks)
Another good station to score points. We did not have a separate station for ultrasound, for us it was clubbed with the ATLS station.so only USG we had to demonstrate was EFAST. Will not be the case with all centers. Don’t rely on it.

Things you need to be familiar with are:
Use of the machine
Use of different knobs.
Optimization of the image
Focusing of the image
E FAST
Lung ultrasound
Abdomen ultrasound
Leg ultrasound
ECHO
Diagnosis based on the ultrasound findings and treatment
Ultrasound protocols in shock

V.VIVA
The viva where my exam was held consisted of Thesis, Waste Disposal and Recent advances in Emergency Medicine. This again may be subject to the choice of different centers, but the thesis is very likely to be included and it is one of the things you can prepare for. Carry your thesis, obviously. I had carried a completed logbook as well, but it wasn’t asked for, at my center.

Thesis: you are required to be familiar with study population, study methods, main findings, why you chose to do this study, what results the recent studies in your topic have shown (remember your thesis would be a year old before you take the viva :P )
Waste Disposal: which articles, which colored bags.
Recent Advances: well, any area of EM. You either know it or you don’t and it’s ok if you don’t. The entire viva lasted for about 10 minutes although the bell rang at 5 minutes.

And then, I was done.

In the end, I have to acknowledge and all of us did, that the standard for conducting the DNB EM practicals is quite high and we are not trained to face it in most institutes. The only reason I cleared the exam, and I say this with all honesty, is because of the help and assistance provided by seniors who had previously cleared the exam and discussed these things on WhatsApp about 3 weeks before the exam. And the assistance of friends who took the exam with me, who were well trained and well advised by their superiors, who helped me with insight and learning in the last minute. Please don’t make your practical exam preparation as haphazard as mine.

Begin your preparation in the first year and take help from well-meaning seniors.
All the best.
Be better every day.


Manasa Seshadri 

Ankle Block (Landmark Technique) - Procedures

Ankle block covers the five nerves around the ankle joint. Three nerves are located anteriorly and supply the dorsal aspect of the foot. Two nerves are located posteriorly and supply the volar aspect. A complete nerve block of the foot requires blocking three subcutaneous nerves and two deeper nerves. Overlap of the sensory distribution frequently necessitates blocking multiple nerves for adequate anesthesia. 

1. Deep peroneal - Deep - Supplies Anteriorly 
2. Posterior tibial - Deep - Supplies Posteriorly 
3. Saphenous - Superficial - Supplies Anteriorly 
4. Superficial peroneal - Superficial - Supplies Anteriorly 
5. Sural nerves - Superficial - Supplies Posteriorly 

Depending on the desired area of anesthesia, one or more of the five nerves are blocked. Nerve block of the sural and posterior tibial nerves together anesthetizes the bottom of the foot and is the most useful combination.

Indications

Procedures on the foot (lac repair, I&D, FB removal, wound irrigation). The rationale for using Ankle block over infiltration anesthesia on the sole is that skin of the sole is thicker and more tightly bound to the underlying fascia making skin puncturing quite difficult and painful. Large amounts of anesthetic on sole may lead to painful distention of the tissue and circulatory compromise of the microvasculature.

Relevant Anatomy and Sensory supply of 5 nerves around Ankle Joint

Image from Roberts & Hedges - Clinical Procedures in Emergency Medicine

Site of Injections (2 deep injections and 3 bands)

1. Posterior Tibial Nerve - Posterosuperior to the posterior tibial artery between medial malleulus and Achilles. At a depth of 1 cm, inject 3 to 5mls of anesthetic.

2. Deep Peroneal Nerve - Palpate the EHL and anterior tibial tendons (Ask the patient to dorsiflex the foot and big toe) and inject 3-5mls LA 1 cm superior to the medial malleolus under the EHL tendon until it strikes the tibia. 

3. Superficial Peroneal - Inject 4 to 10 mL of anesthetic subcutaneously in a band between the EHL tendon and the lateral malleolus. 

4. Saphenous - Inject 3-5ml of LA subcutaneously in a band between the medial malleolus and the anterior tibial tendon. 

5. Sural Nerve - Block at the lateral aspect of the ankle between Achilles and the lateral malleolus. Inject 3 to 5 mls of anesthetic subcutaneously in a band like fashion at about 1 cm above the lateral malleolus. 

All five nerves can be blocked by placing subcutaneous band blocks around 75% of the ankle circumference and two deep injections: one next to the palpable posterior tibial artery (Post Tibial Nerve) and the other under the extensor tendon of the big toe (Deep Peroneal Nerve).

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

DNB Emergency Medicine (Diplomate of National Board )

Guest Post by Manasa Seshadri 

I gave my final DNB theory exam, in Emergency Medicine in June 2018. And I cleared the exam. We had 4 papers, spread over (crammed in) 3 days; second day with one paper in the morning, one in the evening. Each paper was for 100 marks, with 10 questions in each. 

The following is few points I had written , about things that helped me prepare for the theory exam and thank god, clearing it. Have edited it a little and sharing it now. I have written these points for my current field, Emergency Medicine. Parts of it will be helpful for all specialities. These are specific for DNB theory, I say that only because of lack of knowledge about how MD guys prepare, maybe quite similar, their question paper pattern differ from DNB though.

Please ask your seniors and others for advice. Their advice may differ from mine. Follow whatever you feel more comfortable with.

To pass an exam, you will need 6 months of preparation. That’s a minimum. Start now if you are late, start now if you are early.

BOOK : The only book I read was Tintinallis. I had planned to read some special books for paediatrics and trauma, but ended up not reading anything else because of the familiarity I had gained with Tintinallis and because I wasn’t sincere enough to make time for reading anything else. Your seniors may suggest other books for you. Please keep your options open as I haven’t seen any other book as of now, to offer an opinion.

If you are reading the book for pleasure, to understand the subject, to have fun while reading, do it before the last 6 months, because none of this pleasure reading will count when you are writing your paper 

Following is just for the last 6 months of reading:

CAN I OMIT ANYTHING? The answer I believe is, no.Read every line from the book. Including history and epidemiology – they asked us history of Nipah as a part of 10 mark question on Nipah(it was expected that we would be asked about Nipah, but history of the disease might have been something we wouldn’t have taken seriously) . I wouldn’t take the risk of omitting anything because it feels irrelevant or odd to be asked as a question. 

NOTES. I can’t stress the importance of making notes more. Make notes. Of everything you read. From any book / journal or paper you read. This notes will be the only material you should be reading during your revision. The revision you will be doing in the last 20 days/ 1 month or if you are sincere enough, last 2 months before exam! What you read in last 20 days is the only part you will remember when you are writing the paper.

Notes can be hand written (I prefer this method being an old fashioned person that I am) or typed (very satisfying for the OCD types and for those who know your way around the “bullets” and “changing list level” while using bullets in the word doc (I am not the one who is good at this and unfortunately I selected this method) Sounds nerdy, but helps knowing your type before you start. Notes should be pointers/ one liners or just 4 or 5 words in a line. That’s how you write your answers in the exams too. 

Notes will give you a perspective of what you have read, help you understand the chapter and help you prepare your answer for the exam, so that you need not spend any minute getting creative and spinning a story when you are writing the exam, and just write down the points you made.

“ENUMERATE “is a thing with DNB papers. “Enumerate causes of post-partum haemorrhage”, “enumerate the cold related injuries” etc. When you are starting the chapter, you can make a note of the main headings covered in that chapter in your notes or a stick-on, because that may just be your 2 or 3 marker. 2 marks seems less now. But when you are receive your question paper in your hand, it’s really a very big number!!

QUESTION PAPERS : You have to know the previous years’ question papers. They cover most topics from the text book, and when you know those topics, none of the questions will seem absurd or shocking to you. You will have 4 years papers in Emergency Medicine, including the June 2018 one, 4 papers each year. Each 10 mark question is subdivided into 2/3 and 4 markers, and each of them are specific, to the point questions. So very minimum scope for storytelling, be warned

If you are starting with question papers, finish the entire chapter from which that particular question has been asked. At the end of 4 papers including the recent June 2018 session, you will end up finishing 150 or more chapters of the total 303 chapters in Tintinallis book.

TABLES : you will know when you do the papers how many questions can be answered by knowing the tables and figures in the text book. 1 of those 3 or 4 sub- questions will invariably be a table from that chapter. Learning tables is near complete rote, so keep time to revise the tables again and again. And again. Your mnemonic habits from PG entrance exam preparation will be handy here.

REVISION : you need 3 months for revision, at least 2 months. And 3 times revision. They may say no, but most students from all departments revise atleast 3 times before final exam. Also, I am a slow learner. I am sure, there are people here, who need less time to read or revise, so decide for yourself how many months or how many times revision you need before exam. For a 6 month preparation period - If you are setting aside 3 months for revision, you have 3 months to finish first time reading. That’s 303 chapters in 90 days. That’s 3 chapters per day on an average. Luckily you have a lot of 3 and 4 pages small chapters in the book. Club them with 10 or 15 page chapters and read them. 

It’s ok if you don’t finish all 303 chapters in this first 3 months. Stretch your first time reading to 4 months and keep aside 2 months for revision. Keep track of the chapters you have never looked at (these are the moulds that you never felt comfortable looking at. Keep a separate track of chapters that you need more time to revise, that you need to refer from other sources . “Keeping track” may sound childish, but it helps you not feeling overwhelmed, and that’s a good thing when you are preparing for exam.

Study for a fixed number of hours in a day. 

Set aside those hours depending on your comfort, discipline, sleep wake cycles that you are habituated to. 

Exercise.

Watch movies.

Take short trips.

Enjoy studying. 

All the best.

Confession - I solemnly swear I didn't stick to the plan I enumerated above, wish I had though but sure as hell, I had planned it. Please do better than me. It will help.

Manasa Seshadri 

Diplomate of National Board (DNB) is a title awarded by the National Board of Examinations (NBE), an autonomous academic body under the Ministry of Health and Family Welfare, Government of India to candidates who successfully complete their postgraduate or postdoctoral medical education under it. DNB is recognised by the Government of India. Also, the Ministry of Health and Family Welfare has issued notification mentioning that DNB should always be considered equivalent to MD. 

Who owns the airway?

In modern day medicine, these are countless specialties and sub-specialties that we can explore. There are fellowships on heart failure, fellowships on particular disease entities and so on. But there are some things that remain very basic such as basic airway skills that every physician must know. In contrast, who is the expert in advanced airways is a matter of debate though? Is it Emergency Medicine, Intensive Care, Anesthesia or ENT.  

Managing Airways depends a lot on local protocols and systems but in general, it is either ITU, Anesthetics or EM personnel who do this. During initial bits of my training in a missionary hospital I learned and mastered my basic and advanced airway skills. I was fortunate enough to work with some of the finest EM and ITU gurus in the country. By the end of two years, I was pretty confident about my airway skills. Particularly at Vellore, Airway was definitely an EM physicians territory and I don't recall a single day when Anesthetists were summoned to ED for any airway. Later, I moved to a corporate hospital in Hyderabad where once again - Airway was an ED doctor's forte and Anesthetist/ENT was rarely called to ED to help with airways. 

Surprisingly, a large population of EM physicians/trainees believe that Airway is best left to Anesthetists since they are experts in managing it. Well, by that logic we should stop reading ECGs, CT scans, X Rays or even doing abdomen exams as they are best done by a Surgeon who has done is 1000s of times. I guess we are getting back to those good old Casualty Medical Officer days..On the name of safety, support, courtesy and expert care we often let down EM as a stand-alone specialty. 

Arguments from those who think Anesthetists/ITU should do all Airways

They do it several times a day and a few thousand times in their residency. So they are the best!

Any seasoned ED doctor understands how you feel when you intubate a desaturating patient with a full belly and high risk of aspiration. This a common scenario in EDs and not in Operation Theatres. ED RSIs are very different from elective theatre intubations. ED intubations happen over a span of few minutes and they should be dealt with a sense of emergency (not urgency). 

Most Anesthesia trainees learn this crucial skill in a well controlled and elective environment and continue to polish it further in controlled settings whilst EM trainees learn this during Anesthetic Rotations/Emergency Department and continue to fine-tune it in A&E under the supervision of a Consultant. 

Post-intubation care is tough and we can't manage that

Really!! EM is a tough specialty and this is not a reason to call ITU/Anesthesia to manage airways. Check this out to understand "post-intubation" care. Not knowing enough and being sloppy is not a valid argument. 

We need more protocols and guidelines 

Until recently, I was a big proponent of guidelines and protocols but lately, I have been questioning and thinking if these are leading to any benefit or more harm. As clinicians, we stop thinking when using these pathways. Patients are thrown into pathways and they all get worked up in the same fashion. Same initial workup for a 20yo Chest pain and  40YO Chest Pain and 65yo Chest Pain - unnecessary blood tests, false positives, invasive testing, incidentalomas and serious harms from procedures + inappropriate utilization of resources. Hopefully, things would not be the same for "Difficult Airway Pathways". I certainly believe that we should have difficult airway pathways in ED formed in liaison with Anesthetics/ITUs but we should NOT be summoning them for every airway in ED. Emergency Departments should have their own protocols for intubation and ED should be able to decide on intubation.

The Designation Bias and "EM Mindset"

Many are of the opinion that a patient does not need intubation when GCS is 9/15 (not <8/15). Well, it is not that simple. So here is my list of those patients who needs intubation (This is not an exhaustive list):

• Respiratory Failure or Impending Respiratory Failure (Type 1 or Type 2)
• Cardiac Arrest 
• Airway Patency issues or Potential Airway compromise (Low GCS, Head Injury, Neck Masses, Stridor, Burns, Anaphylaxis)
• Anticipated Course of Care 
• Unresponsive Shock
• Raised ICP

The way EM and Anesthesia think about "Emergency Airway Management" can be very different. If Anesthetics fail the airway in the first attempt, it is called a difficult airway but if ED fails in the first attempt, it is called as incompetency. (Designation bias)

Strong Leadership and Getting Support from Colleagues

The practice of EM is extremely variable in different parts of the world. There is often an overlap with Pre-Hospital, ITU, Anesthetics. To progress as a specialty, it is important to have a quintessential group of mentors who love what they do and want to progress EM as an individual specialty. Sadly, this is not always the case and EM is governed by other specialists with little or no EM training. Once in a while, things do go wrong with high-risk procedures and having support from your colleagues is then of utmost importance. This is only possible if the whole body of senior doctors is on the same page regarding airway protocols.

Summary

Managing airway is not left to an individual specialty anymore. It is a skill shared by EM, ITU, Anesthetics, and ENT as well. 

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Leading the shop floor - Unsolicited advices!

Night shifts tire out A&E doctors and lead to considerable amount of distress. Things can go worse due to lack of staffing, complicated patients (who always turn up during these hours), unfamiliar (or familiar) locum doctors around. Explicit details vary depending on the "local settings and culture of Emergency Medicine" but overall theme remains the same to manage a busy department overnight. By morning, we end up signing countless ECGs, ordering several medications (with minimal background info available) and listening to numerous SHO/F2 case presentations. Essentially, we walk on the very thin ice during night shifts and there are good chances of making errors. 

Is there a way to circumvent this or at least minimize this risk?
What can we do to manage flow better and avoid handing over an 8 hour waiting time?

1. Using checklists

• Procedural Sedation Checklist
• Resuscitation checklist 
• Post Cardiac Arrest Care checklist
• Reading a CXR checklist
• ECG checklist 
• Discharge Checklist
• 
  

These can reduce cognitive overloading, save time and minimize errors, especially during the busy hours.

2. Listening to FY/SHOs presentations 
Take time and set rapport with your night team. Get a sense of their background, previous experiences and what rotations they have been through so far. Allocate tasks keeping this in your mind. Early on, try and see (at least eyeball) every patient that they are allocated and once you understand their clinical acumen, go with that. 

Being approachable with junior doctors is they key for patient safety. Ask them if they are concerned about anything in particular or if they want you to examine the patient. 

3. Documentation and Risk Management 
Diagnostic uncertainty is a part of Emergency Medicine. it is almost impossible to come with a definite diagnosis within a span of few hours. Sometimes, it takes weeks and months to reach a definitive diagnosis after several out-patient visits. Our job is to think about life threats. We work on the basis of probability and likelihood. Explain this to a patient. Most of them will appreciate and just need some reassurance. Prepared scripts can be useful here. For instance, discharging a low-risk chest pain. Document a clinical decision rule such as HEART score and tell them that:

Based on our evaluation today, your blood reports, and serial ECGs, your risk of heart disease is extremely low. I think your symptoms are likely due to acid reflux. I am going to prescribe some medications and discharge you. With aging, we all develop some degree of blockage in blood vessels around the heart and you may have that as well but this does not mean that you are having a heart attack. You need to follow up with you General Practitioner as an out-patient for further evaluation, see response to reflux medications and a for a definite diagnosis. However, if things change anytime i.e you feel unwell, sweaty, dizzy, short of breath or concerned about anything else then please come back to A&E and we will be happy to assess you again. We are here 24x7. 

Document this conversation briefly in the chart briefly under "Medical Decision Making". Your chart should depict your thought process and rationale behind your decisions. Use scoring systems like Wells, PERC, HEART to manage risk. Occasionally, you will see a patient who asks for a 100% definite diagnosis. Ask about their concerns and set expectations as soon as you see them. If you are sending someone home who looks clinically very well but with a unclear diagnosis, safety net them and arrange further follow up as an out-patient. 

Documentation: It is best to finish documentation/clerking as you go rather than carrying a bunch of charts with you to finish after the morning handover. After the handover, you would want to leave the ED ASAP and this will certainly compromise the quality of your notes. Write explicit and legible notes. 

Patient info leaflets and discharge advice: If you think they are going home, hand over specific discharge leaflets to them beforehand. Tell them to have a glance through them and ask any questions. This keeps them busy and helps to understand their ailment better. Moreover, you are medicolegally safer since you hand over written red fags to them specifying when to return to ED.

4. Triage led blood sets (for minors) - to expedite decision making

• Young Chest Pain 
• Pleuritic Chest Pain 
• CP with risk factors
• Abdo pain female
• Abdo pain male 
• Shortness of Breath 
• Needle Stick Injury
• Febrile Illness
• Fever in Traveller 

Triage led to blood tests based on chief complaints improves the flow but these should be interpreted carefully. Sending troponins for every 20yo with CP will lead to nowhere and may lead to unnecessary further testing. I advocate that tests such as d-dimer and hs-troponin should only be ordered after discussion with a consultant or any senior physician whenever possible. Both these tests are very non-specific but if used judiciously, they can be very useful. Routine second troponins lead to unnecessary long waits and prolong the length of stay. False positive d-dimers subject patients to the unnecessary risk of anticoagulation and follow up. 

Avoid "just to be sure" type of investigations. Do not start hunting for problems in a well-looking 90-year-old. Follow guidelines for imaging and deviate only if you feel strongly about something. If a blood test is not going to alter your management, then don't do it. Check out RCEM guidelines on redundant activities here. 


5. Situational Awareness and communication
While running the show as a registrar (equivalent to final year resident in the US), do less and allocate more. Having a good sense of what is going around with patients seen by junior doctors is crucial. Anticipate further care needs of every patient. For instance, eyeballing patients on arrival and organizing imaging such as X Rays and Head Scans can save a lot of time. Ask yourself:

• What can you do for this patient in ED?
• Who is well and who is sick? 
• Who needs admission and who can be discharged?

Seasoned clinicians almost always decide to admit v/s discharge after 2-3 minute conversation with a patient, occasionally just after eyeballing a patient! Verbalise a clear plan to junior doctors and if possible, write it on the chart. 

Keep a track of co-morbidities and social issues (carers, living alone, frail elderly demented, homeless, domestic violence) before discharging patients. Think twice before discharging an elderly during twilight hours. On a 10 hour shift, I typically spend just about 1 hour with patients and rest of my time goes in getting things done - requesting scans, discussion with Radiology and inpatient teams, adding blood tests, calling labs, difficult cannulas, and most-importantly documentation. When running the shop floor, it is important to delegate as much as you can. 

• IV Cannulation - Ask the nursing staff to keep the USG machine and equipment ready
• Joint reduction - Ask FY/SHO to prep everything - hook them to monitor and keep sedation drugs ready 
• FAST/AAA Scan - Move the patient to a room and keep the USG machine jelled  
• Wound Repair - Procedure nurse to prepare equipment 

If you are leading the department, then your time is precious. Everyone will be out there looking for you (nurses, junior docs, angry patients, in-patient teams, difficult referrals) and don't involve yourself in something time-taking procedures. 

I work in an enormous ED and it can take me up to 2 minutes to walk from one end to the other. Having a list of phone numbers of HDU, Minors, Resus, Assessment areas can be immensely useful. You can then just call and liaise with nurses rather than physically going to each of these areas. 



Communicate with nurses : Nurses are the backbone of your team and if they stand by your side, things go very smooth. Know them by their names and let them know that you are running the shop floor before you begin your shift. Assign them tasks like putting back slabs, getting medications quickly, patients who need monitoring and frequent observations. 

6. Calling for help
Knowing our limitations is crucial and we must know what we exactly want a specialist to do when we call for a consult. Whether it is ITU, Anesthetics, Trauma team - the theme remains the same. Whenever possible, know their names and with time set a rapport with them. Developing negotiation skills while conversing with a specialist is a skill that we all must learn. 

7. Safeguarding and other clerical work 
On a busy shift, the last thing we want is a doctor held up in sorting out safeguarding and social issues for a patient. Undoubtedly, these tasks are important our job should be to raise concerns about them. FIlling 6 page long referral forms and sending e-mails to a group of people can be very time-consuming and this can seriously halt the flow of the department. I strongly believe that these tasks would be best done by a clerk (non-medical) as this does not require a medical degree. 

If you have anymore thoughts on this, then please feel free to comment and share your wisdom.

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic