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.

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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.