Où Allons Nous

I’m on the cusp of the ACEM fellowship clinical exam, surrounded by practice OSCE stems, motivating phrases on a white board, and self-critical thoughts about neglected relationships. This milieu is a psychologically provocative one and I find myself reflecting on a particular piece of art by the synthetist painter Paul Gaugin:

D’où Venons Nous / Que Sommes Nous / Où Allons Nous
(Where do we come from / Who are we / Where are we going)

Paul_Gauguin_-_D'ou_venons-nous

Where from?

I stumbled into medicine by chance.  Despite coming from a medical family, medicine in general had never been part of my life agenda. My father, a rural generalist solo practitioner, discouraged me from medicine for the first two decades of life.  After following a crowd into law school post- high-school, I dropped out after one day to begin a stillborn apprenticeship as a chef.  The cooking business lasted a year: by chance I read a book by Russian journalist Anna Politkovskaya on the Russian invasion of Chechnya, which was catalytic in reorienting my career aspirations. Medicine became a craft with a tangible, portable skillset that could be exercised in the spirit of social justice. I was able to piggyback off my high-school grades into medical school and muddle my way though, collecting a handful of mentors along the way. A tragic aside – Politokovskaya was murdered in my second year of medicine – the murder motivated by her social justice advocacy through journalism.

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Anna Politkovskaya, 1958 – 2006 – an unfinished life

Who?

Patients often ask me if I am married. I usually make some nonchalant self-assured remark about having a couple of children and a mistress – two kelpies and the emergency department. Beneath the glib attempt to put patients at ease, there is a troublesome reality – without imposing boundaries on medicine, it could easily come to define my life. I am thankfully able to rein it in by fostering a broader perspective on life, society, the environment and the cosmos.

Truth be told, I am far from self-assured. I generally feel like a confused albeit cultured ape. I take pride in honing my clinical credibility and delivering care to vulnerable, anxious and wounded fellow primates. At the same time, I feel ashamed by waste, pollution and potential harm I do to the planet and to patients, as a cog in the enormous wheel of the medical industrial complex. I feel uncomfortable that this technology driven-wheel tends to grind for the haves at the expense of the have-nots. I feel no satisfaction spending public money on exercise stress tests (up to 24 false positives for every 1 true positive in women), or other no-value investigations, therapies or procedures. At the same time, I feel immense satisfaction when I connect with patients and provide explanation, reassurance or comfort. These dilemmas pervade the rest of my life as well. Should I respond to climate change by not having children? Or should I not worry about the planet since we’re just a pale blue dot anyway? Accepting the uncertainty of existence makes accepting uncertainty in medicine much easier.

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The blueish-white speck of Earth with 6 billion kilometres of perspective. Voyager 1, 1990

Where to?

Training in emergency medicine has been a wonderful journey. The cobbles are now more familiar than when I was a truant medical student, however I’m not sure familiarity is where my future lies. I’ve no doubt emergency medicine could be harmonized within the context of the cosmos, but the model of health care in the industrially developed world seems to stray farther and farther from the reasons why I took up the stethoscope in the first place (ultrasound actually; I don’t own a stethoscope).

Paul Gaugin gave up a career as a stockbroker to learn art and paint his way around the world. Perhaps I too may choose a path less worn. Thus far, emergency medicine has gifted me with instruments necessary to manage complexity, uncertainty, stress, conflict and high emotion. Ultimately, I know that wherever I chose to navigate my future, be it in EM or art, I’m well equipped to sail around the shoals and find safe harbour.

Thomas Brough, May 2018

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Rosie and Jade already know how navigate the tricky waters of life
without losing sleep over exams, missed diagnoses or stroke thrombolysis.

The Procedures Course

This week we got 9 of our consultants through The Procedures Course. Added to the one who had already done it, that is half of our senior staff having done the course now.

There are a lot of useful courses around these days, with higher and higher expectations of acute health care and fewer opportunities to maintain skills in the workplace due to specialization, safer working hours and the expectation that clinicians will not learn something new on a critically ill person without having some sort of qualification or experience in it first.

This course is a bit different from most. While the wonderful world of simulation has brought us the chance to practice many critical cognitive and technical skills in safe environments, the use of cadavers in medical training has really dropped off. In Australia, more than the US, we have a squeamishness about cadaver training. As a medical student I spent several hours a week for the first year and a half on cadaver based anatomy workshops but that is largely gone from modern medical training. Clinical training with cadavers remains quite uncommon here.

Thanks to the enormous generosity of the people who asked to donate their bodies to medical training before they died, and the hard work of the team from the Alfred Emergency and Trauma Centre and Trauma Unit, supported by expert faculty including neurosurgeons, ophthalmologists, obstetricians, orthopods and others, we were able to learn and practice a raft of life, limb and sight saving skills this week. It is hard to describe how much more capable I feel as an emergency physician having done this course, and I’ve been one for a while now!

Check out the course website, not that they need the publicity, they have sold out their next course already.

Hog Fat… Is there anything it cannot do?

I’m showing my age clearly because when I searched for that quote online to get the youtube clip of Homer Simpson uttering the words in wistful admiration of a power station powered by hog fat, it was nowhere to be seen. Now that I think of it, that episode probably predates youtube.

Anyway, down to business.

Khiem Ngo has just joined the Bendigo ED Education team as Co-DEMT. I have him to thank for bringing us this innovation.

When you have eaten all the crispy pork belly you can possibly eat (impossible?) use the left overs to create a peripheral IVC ultrasound phantom that is more realistic than any you will buy commercially.

 

Ingredients

  • Pork belly or waste pig skin (ask your butcher as they will often have some that is destined to be tossed out)
  • Long skinny balloons used for making balloon animals
  • Water

Method

  • Fill balloon with water but don’t distend it. Tie it off.
  • Cut pig skin into strips 4-5 cm wide and 15 cm long (2 inch x 6 inch)
  • Blunt dissect a tract through one of the fascial planes. We used a dilator from an expired pigtail catheter set but you could probably use a biro or pencil
  • Use a pair of long artery forceps to feed your balloon through the tract
  • Massage out any air bubbles along the tract

How much does that scan cost?

When I started out as an EM trainee, having dated a radiographer I was very cognisant of the radiation penalties from medical imaging as well as the associated risks of developing a new malignancy.  Over time my conscientiousness in requesting radiology has waned.

My individual threshold for imaging remains relatively high, especially in circumstances where validated clinical decision instruments determine further work-up to be unnecessary.  Nevertheless, arguing the toss over imaging vs not imaging with other teams (who will likely ultimately be responsible for the patient’s care) becomes intellectually frustrating. It is usually easier to facilitate care by ordering a scan and saving one’s energy for something else. Like stroke care. No wait…. forget that one too.

In equivocal cases, appealing to the attendant radiation penalty of a study may encourage deferment in favour of clinical observation.  I put together this infographic to help facilitate such a conversation, and to help me quantify radiation dose and risk of malignancy in preparation for my fellowship exam.

Another way to look at it: if you’ve spent a metaphorical $20,000 worth of medical radiation you’ve probably given someone cancer. And made a radiologist wealthy. Let’s budget our radiation wisely.

P.S. If you’re prepared to pay with personal time to study and scan, ultrasound is free 🙂

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ED management of the Acutely Agitated patient

We all know what it is like to have an acutely agitated patient present to your ED. It is challenging, intimidating, dangerous and disruptive for your staff and and your other patients.

It can be difficult to take a step back from the evolving situation and assess . You may be consumed by the desire to regain control of the situation. It may be difficult to think about (let alone treat) whatever pathology is underlying.

What is ABD?

ABD = acute behavioural disturbance. There are several similar definitions and terminology used can be confusing (excited delirium, acute agitation or drug intoxicated or drug affected behaviour). My favourite is from the Royal College of Emergency Medicine in UK

  • Sudden onset of aggressive and violent behaviour and autonomic dysfunction
  • Often occurs in the setting of acute drug ingestion or serious mental illness

ABD is a presents as a spectrum of features that includes acute delirium, agitation as well as as adrenergic dysfunction

It is associated with sudden death in 10% cases and there have been several high profile deaths in recent years in several countries

It is important to recognise and to treat it quickly

How many patients are affected in Victoria?

If we look at 2013/ 14 Victorian ambulance data and assume that crystal methamphetamine-related presentations are resposible for most of our ABD patients then we have

  • 3.4 ambulance attendances per day (0 to 10 patients) in metropolitan Melbourne
  • 0.8 ambulance attendances per day (0 to 6 patients) in regional Victoria
  • Most patients present between midday and 6pm in metropolitan Melbourne, between the hours of 6pm and midnight in regional Victoria
  • The peak day was Sunday in metropolitan Melbourne, the peak day was Saturday in regional Victoria

What are the typical symptoms?

A person can display mildly erratic behaviour ranging to extreme agitation and physical exertion

Things to look out for

  • extreme aggression, violent behaviour
  • excessive strength/ continued struggling with police restraint
  • reduced reaction to pain
  • acute psychotic state
  • hyperthermia, tachypnoea, tachycardia

ABD patients may have symptoms that are similar to other conditions. Other things to think about are

  • hypoxia
  • substance intoxication or withdrawal
  • hypoglycaemia
  • head trauma
  • CNS infection, haemorrhage
  • seizure, stroke or post ictal state

Describe general management principles for this patient group?

The general approach to these patients is very important

Remember you are dealing with one of 3 different types of patients

  • cooperative
  • disruptive not dangerous
  • excited delirium

Listen to Reuben Strayer give a fascinating talk about this at #SMACCDUB in June 2016

General principles that I try to implement

  • Evaluate your patient in safe area – evacuate other patients if this is in the ambulance entrance area
  • Make sure your staff is safe, are there any concealed weapons, can you move the patient to a secluded area, involve your security staff early. Call a Code Grey!

De-escalation techniques are important

  • talk to your patient in a calm and confident voice
  • do not confront your patient
  • do not maintain prolonged eye contact
  • never stand over them
  • offer them food or a cigarette if this is appropriate
  • try reduce the amount of ‘testosterone’ in the room if it is safe to do so

Different patients will respond differently and there is no one approach that fits

Some patients are unsuitable for de-escalation and physical restraint may be required. This is defined as the ‘intentional restriction of a person’s voluntary movement or behaviour by the use of a device, removal of mobility aids or physical force’

In most cases, in ED we will use category 1 restraint (emergency single episode restraint) and documentation must include – reason for restraint, condition prior to restraint (see SAT score), form of restraint applied, details of event, length of time restraint was applied for and condition post restraint. Restraint devices should be removed as soon as the patient is adequately sedated

SAT tool for sedation assessment

The Sedation Assessment Tool is a 7 point scoring system, based on level of arousal and speech patterns

  • It was described in Emergency Medicine Australasia in 2011
  • It ranges from plus 3 which is highly agitated to minus 3 which is heavily sedated
  • Endpoint for sedation is -1 (patient is drowsy but rousable)

 

SEDATION ASSESSMENT TOOL (SAT)
Score Responsiveness Speech Scale
+3 Combative, violent, out of control Continual loud outbursts +1 to +3

Agitation

+2 Very anxious and agitated Loud outbursts
+1 Anxious/restless Normal/talkative
0 Awake, calm Speaks normally 0 = normal
-1 Asleep but rouses if name called Slurring or slowing -1 to -3

Sedation

-2 Responds to physical stimulation Few recognizable words
-3 No response to stimulation Nil

 

What drugs can you use?

Chemical sedation or rapid tranquilisation may also be required for an ABD patient.

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Australia is fortunate to have access to droperidol, this is thought to be the first line agent to treat most cases of  ABD. However it is not available in Ireland, UK or in the USA

The main drug categories I use are benzodiazepines, antipsychotics and sometimes ketamine

Benzodiazepeines are familiar to most emergency doctors, they are safe you can give them via the oral and parenteral route. The main side effect to watch out for is respiratory depression. Lorazepam is not readily available in Bendigo Health and this acts as a useful bridge between (short acting) diazepam and other longer acting agents

Antipsychotic medications include droperidol or olanzepine. They are dopamine receptor antagonists and this is why they may work well in ABD – theory is that is caused by dopamine excess. Be careful with acute dystonic reactions

My treatment approach is based on the patient’s SAT score

  • SAT +1 – patient is cooperative 

Offer them something orally – use diazepam or olanzapine – any sedative will suffice

  •  SAT +2 – patient is agitated, vocal loud and probably hard to reason with

Now they are disruptive (but not yet dangerous) this is a difficult group to treat and requires tactical negotiation and experience

If possible try something oral but you may need IM meds early

Start with droperidol 5 – 10 mg IM and wait 15 minutes to see how this works

Repeat this dose if needed and now add in midazolam 5mg IM as a 2nd line agent

  • SAT+3 – your patient is aggressive and dangerous this is a full blown excited delirium!

Draw up 2 syringes – 10mg IM droperidol and 10mg IM midazolam

Use an IM injection and get your patient to resus to monitor them

What about ketamine – can I use it?

Things to consider

  • In recent years, there has been a splurge in the number of articles written by authors espousing the use of ketamine for the “Chemical takedown”
  • We use IM ketamine sucessfully for paediatric sedation – it is reasonable to consider it’s use in this situation
  • Many of the studies that describe droperidol use are done in Australia – maybe this is why ketamine has not been adopted (yet)
  • Ketamine has been incorporated into Victoria prehospital guidelines as a first line agent in excited delirium – see CPG A0709
  • A suggested single dose agent  is ketamine 5 mg/kg IMI, see Reuben Strayer again
  • My feeling is that ketamine will be introduced on a gradual basis once practitioners become more used to using it

Post sedation care for ABD patients

  • Be careful with a patient that may have taken a combination of drugs – benzos could cause respiratory depression or hypotension in this group
  • If you get IV access once the patient is settled then you could use this for further doses – no need to make this a priority at the start
  • Monitor them as if the have had procedural sedation – this means regular pulse ox, ECG and BP monitoring as well as SAT score
  • If a patient develops a dystonic reaction as a result of antipsychotic use then reach for benztropine 1-2mg IV
  • When the patient is sedated, the care is mainly supportive – check electrolytes, rehydration will often be useful, do a full examination and get imaging if this is indicated

What does the literature say about drugs for ABD?

The science here is pretty scarce

There have been a few papers published in recent years – led by Australian authors

  • The 1st DORM study was published in the Annals of Emergency Medicine in 2010 by Isbister et al. It used 3 arms to compare droperidol, midazolam and the droperidol/ midaz combo for 91 agitated ED patients.It showed that there was no difference in time to sedation when using droperidol, midaz or the combination. There was less top up sedation needed when the combination was used and the incidence of prolonged QT interval was the same in all groups
  • DORM 2 was published in the Annals of Emergency Medicine in August 2015 by Calver et al. It had over 1000 patients in a prospective observational study across 6 Australian EDs. Their main finding was that droperidol was safe to use for sedation – 13 of 1009 patients had abnormal QT intervals and 7 of these were using another medication that could explain this. DORM 2 had it’s limitations but seems to support safety of droperidol
  • The SOOTH study was been published in 2016. This was a RCT in 2 Melbourne metropolitan EDs and included at 349 acutely agitated patients requiring intravenous sedation. The authors found that midazolam and droperidol used IV for sedation is better than monotherapy using either droperidol or olanzapine alone

What about children?

If you are faced with an agitated child the general management principles remain the same as in adults

  • deescalate the situation
  • offer oral sedation first, parenteral sedation if needed

The Royal Children’s Hospital Melbourne guidelines suggest a treatment algorithm

What does #FOAMed say?

There are many fantastic resources listed on this topic – here are my favourite

Listen to some of the experts talk about how you could manage the agitated patient

Also listen to the podcast that I recorded this month for RCEM FOAMed network with Andy Neill

Take home points to consider

  • There are many drug regimens that are available and safe
  • If you are a trainee, there is no need to be too gung-ho to use new drugs that are outside your EDs normal practice, talk to your bosses and choose wisely!
  • If you are a consultant developing a new policy then talk to your colleagues and see what others are using and what you could use in your setting
  • A combination of droperidol and midazolam seem to be the standard in Australia at the moment

Promises from #ACEMVIC16

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If you enjoyed my talk in Torquay and you want to know more about #FOAMed and how you could benefit from using Twitter here are some resources that you will find interesting

Enjoy your journey on Twitter and I hope that you find it as fascinating as I have! Feel free to message me if you have any queries about this

@cianmcdermott