Simulation: COPD and Pneumothorax 01/06/17

Simulation Scenario

Patient with known COPD, presenting with DIB. X-ray showed large pneumothorax.

Discussion points
- Medical treatment of COPD (Charlotte's Notes) (RCEM Learning - Breathlessness)
- When to start NIV
- Seldinger technique for pneumothoraces (Charlotte's Notes)  (RCEM Learning)
- Use of ultrasound (RCEM Learning)


Human Factors
- Taking time
- Not pre-judging what the scenario will be
- When to ask for help


HAP6

Parkinsons and Critical Appraisal - 24/5/17

1. Parkinsons Nurse on Parkinsons
 Linked to a journal article
 For further resources, we might like to look at RCEM Learning 

CAP12, CAP2, CAP30, CAP4, CAP8, CC1, CC2, CC3, CC4, CC5, CC6, HAP1, HAP13, HAP35, HAP36, HMP5 


2. Critical Appraisal 
Again, if you're needing updates on critical appraisal, look at RCEMLearning. 

We appraised an article looking at age adjusted d-dimers. 

- http://www.bmj.com/content/346/bmj.f2492

There’s a nice discussion http://rebelem.com/age-adjusted-d-dimer-testing/ 

CC20, CC21, HAP29, HAP6, HAP8

20/05/17

Major Incident Training: EL

Procedure, where equipment is, suits.

http://www.rcemlearning.co.uk/foamed/major-incidents-2-incident-plans/ 

10/05/17

Feeding Tube Problems
Presentation on google drive
No curriculum linking

3/5/17 - Obstetric

1. TO - talking ?peri-mortem c-section
  https://coreem.net/core/peri-mortem-c-section/

2. GB - obstetric problems
 Post partum bleeding
 Problems in delivery

Simulation: Trauma in Pregnancy and Conflicting Relatives, and OSCE Practice

26th April

- Domestic Violence case for a pregnant lady
 Remember need to treat the mum, but then consider the fetus (and rhesus)
 Look at the Kings guidance
 Look at RCEM Guidance - http://www.rcemlearning.co.uk/foamed/rcem-guideline-domestic-violence/
 https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0642

Pre Transfusion Bloods
http://www.rcem.ac.uk/code/document.asp?ID=6106

DV Guidelines - https://www.nice.org.uk/guidance/ph50



- "Conflicting Relative"
Remember we might have an unexpected patient
Calling security early can be helpful
Priority is patient care

19/04/2017

Last minute arrangements had to be made as the speaker cancelled at the last minute, but we managed well!

1. Propanolol Update
Talked about what to do if you had a patient with propanolol OD. Reminded everyone that these patients can often appear well, and deteriorate really really quickly.

Remember, propanolol has beta blocker effects and sodium channel blocking effects. This is why it is so dangerous - and can cause hypotension and seizures.
Treatment should be as per toxbase. There is a toxbase app.
ECMO may be a useful bridging tool.
**AVOID PHENYTOIN for seizures - Na blocking **

Article on LITFL.

2. Brief Human Factors Discussion 
It is easier to de-escalate than escalate.
Be careful with locums - not all are familiar with the department.

3. QUIP
RCEM has lots of QUIP resources.
There is always a balance between access, quality and finance.


HAP25

12/04/17

1. Echo in the ED - EF
Lots of good tips and reminders on how to do echo.
Give your links here - http://adultemergencymedicine.blogspot.co.uk/search/label/echo

2. Critical Appraisal of the AHEAD study
The AHEAD study was written before the new NICE head injury guidelines, looking at when they all needed scanning or not.
It has also been appraised here: http://theresusroom.co.uk/the-ahead-study

Our points
- Why was it in BMJ Open
- Who was on the NICE guideline committee?
- This is only one study.
- Do we feel comfortable discussing risk with patients? Should or could they self discharge. If we give patients the information, do we trust their decisions?
- Does this mean we just need to observe people for longer so that we are happy? Bed doesn't do that.
- Their follow up was not sufficient.
- There are a lot of coufounders. including advice to attend hospital is given to warfarin patients, and it is more older patients on warfarin.
- The whole GCS being low thing wasn't very clinically useful as we know we are going to scan a low GCS irregardless of whether they are on warfarin.
- There was quite a lot of missing data which does mean we need to err on the side of caution, but makes the results difficult to interpret. 1/3 of the data was made up.
- Discussion about what is appropriate risk?

Take Homes
- INR is not important or relevant
- Warfarin does increase the risk of head injuries - asymptomatic had 2.7% risk of adverse outcome.
- Some of the symptoms are user dependent - what is amnesia, or LOC?
- We can use this information to prioritise our scans


Curriculum:
CAP 18, HMP 4
HAP 22, HAP 35

15.3.17 - Abdominal Diagnoses

Rectus Sheath Haematoma - http://reference.medscape.com/article/776871-overview

22.3.17 - Data and Derm

Data Discussion 
Facilitated by OG - ECGs
https://lifeinthefastlane.com/ecg-library/ 
https://acadoodle.com/ - recommended by RP

Dermatology
Facilitated by DS

A vasculitis screen comprises:
•       Bloods: FBC, U&E, LFTs, Bone, TFTs, CRP, ESR,
                                ASOT, Hep B, Hep C, HIV, syphilis
                                ANA, ENA, dsDNA, ANCA, C3/4, Rh F/CCP
                                                Igs & SEP
                                                Cryoproteins & anticardiolipin antibodies
•       Throat swab
•       BP
•       Urine dip & microscopy
•       CXR


http://www.pcds.org.uk/p/general-dermatology-table 
http://www.rcemlearning.co.uk/references/common-childhood-exanthems/

PAP18, HAP28

22/2/17 - Simulation - Peri Arrest Neonates

Sessions on Peri-Arrest Neonates 
RCEM Congenital Heart Disease:  http://www.rcemlearning.co.uk/references/congenital-heart-disease/
Metabolic Babies: http://www.rcemfoamed.co.uk/portfolio/metabolic-babies-in-the-ed-easy-as-1-2-3/
NLS Algorithm: https://www.resus.org.uk/EasySiteWeb/GatewayLink.aspx?alId=811

ELS USS and Management Discussion

1. Echo in Life Support - PS 
This was a useful overview of all the different types of ultrasound level one equips us to do, and encouraged us all to start doing RUSH exams in our assessment of unwell and peri-arrest patients.

Echo in Life Support
Charlotte's Notes
Advanced Life Support 
PEA Algorithm

US Journal Club: The RUSH Exam. The Pump, the tank and the pipes. https://t.co/Rl96E2LLla #FOAMed #FOAMus @TempleEM pic.twitter.com/g1goJCgJkH

— Temple EM Ultrasound (@TempleEMUS) June 17, 2015

Mallemat: in shock, use ultrasound to look at HIMAP (RUSH). Weingart's #FOAMed version: http://t.co/9TAivf9M1S #CCEM13 #EMConf

— Lauren Westafer (@LWestafer) September 18, 2013

Shock and Ultrasound

A Better way to Evaluate PEA

Great talk by @CriticalCareNow https://t.co/bMB8msjjTt#smaccDUB #FOAMed pic.twitter.com/dy3cOLNNgh

— Salim R. Rezaie (@srrezaie) June 15, 2016

Had a discussion on how to drain a pericardial effusion. If the patient is arrested - ultrasound guided pericardiocentesis with an abbocath (long cannula) that should be in all of the resus trollies, and the "shock box". If the patient is peri-arrest, transfer to cardiothoracics at Kings, being ready to do a pericardiocentesis en route.
PS suggested Touch Surgery was a useful application to practice pericardiocentesis.

Useful tips for echo in life support
- put the probe on video mode. When you stop CPR, it'll keep "videoing". Then record and interpret.

2. Management - "Make the Doctors go faster" 
We had a discussion on how you make the Doctors go faster! Our main points were
 - your initial role is normally to calm the requester down, as often it's not as bad as they seem
 - check the wellness of the Doctor. They might be struggling with ill health, or they might feel that you are unapproachable.
 - perception is often not linked to reality
 - let their supervisor know if you are really concerned.

Strategies that were discussed were...
- Not letting the potential psychiatric trainees see the psych patients as they will spend the rest of their career doing that, and end up doing a full psych assessment in ED which takes longer.
- Make Drs aware of the time - so you clicked on 30min ago...what have you done in 30min (in a non accusatory way!).
- Pre-empting. Giving people cards and saying it looks like xyz and you need to do this but take a history and see. Most felt this reduced the training of the junior (as RAT can) and made bias more likely. This is why there is no box for ?diagnosis in the RAT assessment notes.
- Balancing departmental needs (long waits) with service and training needs (Doc never sutured, needs to practice).

We talked about whether it was good to know what potential career path people were doing. Some felt it made it more likely you would pre-judge. Others thought it was useful.

This was based on, and supplemented by, a useful article from St Emlyns.


3. 
PS suggested Touch Surgery was a useful application to practice pericardiocentesis.

If you want more podcasts than are freely available (see our resources page), after exhausting RCEMLearning etc. you might like to consider downloading the EM:RAP podcasts. A selection of these are available free but the full podcasts come at a cost. This cost is significantly reduced if you join EMRA.

01/03/17 - Audit Presentations

Audit Presentations

8/2/17 - USS and Anticoagulants

Anticoagulant Use in ACS 

Thoracic Ultrasound - PS
http://adultemergencymedicine.blogspot.co.uk/2015/06/e-fast-pneumothorax.html
http://www.foamem.com/2013/06/11/ultrasound-for-pneumothorax-detection/

15.2.17: Frailty

Website to London trauma network and elderly care guidelines:

http://www.c4ts.qmul.ac.uk/london-trauma-system/elderly-trauma-group​ 

Dr Smithard's presentation available on request - and is on the google drive. 

31.01.17: Teaching

Session One:
Update on Tropical Diseases by AL.


Session Two: 
Didn't quite go according to plan, because of ill health. I've shared the full plan, so you can repeat if you think it worked!

5min brainstorm
  Head injury, no CT needed, probable concussion - what head injury advice do you give?

15min - Do a SCAT assessment on each other.
http://bjsm.bmj.com/content/47/5/259.full.pdf 

10min - BMJ article reading
Read the infographic and article on Concussion      
        http://www.bmj.com/content/bmj/355/bmj.i5629.full.pdf
   
10min - Do we give enough advice about concussion? Do we manage it properly?
Look at head injury advice from elsewhere
https://www.headway.org.uk/about-brain-injury/individuals/types-of-brain-injury/minor-head-injury-and-concussion/ 
http://www.ouh.nhs.uk/patient-guide/leaflets/files/10832Pheadinjury.pdf 
http://patient.info/pdf/4262.pdf 

5min - What head injury advice should we give?

15min  - Sign in to BMJ learning (using your athens account if you're not a BMA member) and complete the Concussion learning. Add it to your CPD portfolio and voila an hour's CPD on concussion
http://learning.bmj.com/learning/module-intro/.html?moduleId=10058380&searchTerm=%E2%80%9Cconcussion%E2%80%9D&page=1&locale=en_GB​              

25th January 2017: Simulation

Simulation Session
LA, AL, LG, CD, LH, SR

1. Hyperkalaemia and Arrest  
Guidelines on hyperkalaemia and reminder of what each treatment does from here, together with clear guidelines for hyperkalaemic arrest.
Look for our guidelines on the intranet - we now don't give insulin and dextrose mixed, but insulin in saline, and dextrose separately if BM low.

Hyperkalaemia 
http://www.aliem.com/2013/mythbuster-calcium-gluconate-raises-serum-calcium-as-calcium-chloride/
http://first10em.com/2016/01/21/hyperkalemia/
http://www.rcemfoamed.co.uk/portfolio/hyperkalaemia/ 
http://adultemergencymedicine.blogspot.co.uk/2016/03/hyperkalaemia.html?m=1 

http://learning.bmj.com/learning/module-intro/hyperkalaemia-diagnosis-management.html?moduleId=6055258&searchTerm=%E2%80%9Chyperkalaemia%E2%80%9D&page=1&locale=en_GB
http://learning.bmj.com/learning/module-intro/hyperkalaemia.html?moduleId=10047565&searchTerm=%E2%80%9Chyperkalaemia%E2%80%9D&page=1&locale=en_GB
http://lifeinthefastlane.com/hyperkalemia/

CPR and ROSC
There's links to loads of other CPR websites at the bottom of my blog post here (too many to copy and paste!).
There are Post ROSC guidelines - and a departmental / local policy
IResus app is available for android and iphone.
I wrote a summary for Foundation Docs a while ago - might be out of date.

Human Factors
There's always time to prescribe - and check medications. Look at this great blog here.
You can look up guidelines like you would in real life - cognitively unload 

Don't be afraid to be a leader. 

That’s Not My Job

 This is a story about four people named Everybody, Somebody, Anybody and Nobody.  There was an important job to be done and Everybody was sure that Somebody would do it.  Anybody could have done it, but Nobody did it.  Somebody got angry about that, because it was Everybody’s job.  Everybody thought Anybody could do it, but Nobody realized that Everybody wouldn’t do it.  It ended up that Everybody blamed Somebody when Nobody did what Anybody could have. 

Remember - if you don't direct your requests, nobody will do them, when anybody and everybody could have. 

2. Overdose and Serotonin Syndrome 

Toxbase app is available to everyone with an athens password - available from the library. 

Remember to do a proper neurological examination in overdose ?what - pyrexia and rigidity should make you think of serotonin syndrome. This needs treatment - you might need to speak to NPIS for cyproheptidine. 

For more information, if you go to googlefoam.com and search, you get loads of handy links. 

Serotonin syndrome vs neuroleptic malignant - I love these flashcards. 

Dantrolene can be given but might make the serotonin syndrome worse - so I'd stay away. Toxbase suggests it for serotonin - but not for serotonin syndrome. Cyproheptidine is recommended on toxbase. 

18.01.17 - Critical Appraisal of PESIT

Present: AL, CG, LH
Facilitating: CG

Paper Discussed:
http://www.nejm.org/doi/full/10.1056/NEJMoa1602172#t=articleDiscussion

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope
Paolo Prandoni et al.  N Engl J Med 2016; 375:1524-1531October 20, 2016

Appraisals Elsewhere
EM Nerd - the PE could be an incidental bystander
REBELEM - scanned only inpatients, 48hour after admission. This study is likely to be an overestimate.
PulmCCM - clot burden is not a useful marker of clot severity. Older patient group. (Also has a useful reminder of pathophysiology).
CoreEM
WikiEM - selection bias
EM:RAP
StEmlyns - is it clinically significant?
EMLit - remember to PERC first!
Spectrum Bias

Pulmonary Embolism
Scroll to the bottom of this link for lots more references and links

Critical Appraisal 
Free courses are run by the library.
RCEMLearning website has loads of free (at the moment) critical appraisal resources.
CASP Checklist

http://www.wessexics.com/The_Bottom_Line/appraisingpapers/
www.guideline.gov
www.tripdatabase.com
www.thecochranelibrary.com
www.cebm.net
http://stemlynsblog.org/tag/critical-appraisal/
https://rcpsg.ac.uk/media/pa/P3/Files/Examinations/Dentistry/ISFE/Introduction%20to%20the%20Critical%20Appraisal%20Section%20updated%20June%202012.pdf

11th Jan Teaching

Present: OG, BA, LH, CD, AL, HA, RP, EJ
Supervising: AH
Curriculum Codes: CC1, CC7, CC12, CC14, CC19, CC21, HAP2, HAP17

Management Case - 
A patient that staff didn't want to allow access to the hospital, ?opiate seeking, challenging behavior. Attending for the third time with the same problem.

- You can only refuse entrance if patient has an ASBO, and doesn't need immediate medical help - see frequent attender guidelines.
- Potential opiate seekers should be given analgesia, even opiates. Remember IVDUs have opiates at home, so there's a reason they're coming into hospital. Look at the college pain guidelines which specifically mention this.
- As they are a reattender, this patient must be seen by the most senior Doctor present according to Consultant sign off guidelines - RCEM standards. As they are a frequent attender, college guidelines also state that they should be seen by a senior doctor.

- If the patient is difficult, and refusing examination you must decide whether they have capacity to refuse. This can be difficult. RCEM Guidelines.
If they don't have capacity, sedate as appropriate, in the patient's best interests - to allow you to safely assess the patient.

Case Discussion
Patient with history of migraine, who attended with collapse and headache, ?SAH.
- Remember that transient loss of consciousness + headache could easily be a SAH.
- Migraine patients don't normally come to the ED with their headache.
- If you have an SAH, the aneurysm pops, you loose cerebral perfusion, get TLOC, and then blood flow returns. They may rebleed. The only way to exclude is CT (read the Stiell paper: within 6 hours, CT alone is normally sufficient) and LP.

- RCEM have a flowchart
- There are NICE guidelines

Other Headache Links
Hamid's CTR on LPs in SAH.
London network guidelines on headache: http://www.londonscn.nhs.uk/publication/adults-with-headache-edu-videos/
TLOC headache guidelines: http://www.londonscn.nhs.uk/publication/adults-with-transient-loss-of-consciousness-edu-videos/
http://adultemergencymedicine.blogspot.co.uk/search/label/headache
The Ottawa headache rules.

4th January 2017 teaching

CD - CC6, CC21, HAP1,
Renal Colic and should we image?
                  https://www.aliem.com/2014/top-10-reasons-order-ct-scan-suspected-renal-colic/ 
                  https://cks.nice.org.uk/renal-or-ureteric-colic-acute
                  Charlotte's CTR: http://bit.ly/2iHv2vq 

BA - HMP5, HAP8
                ECG cases
                http://lifeinthefastlane.com/ecg-library/basics/right-axis-deviation/


Present: CD, BA, LH, AL, FA, SC