Making (non)sense of emergency care models – where do the clinicians fit in? A follow-up to “Where to for EM?”

I read this post when it was first published last year. A great synthesis indeed. I then forgot about it.

Today I finished my first shift as a rat doctor (rapid assessment and treatment/triage/whatever) and followed up the day with an evening of studying crit care echo. For some reason I felt a nagging tension between these two functions, both of which are arguably core emergency physician skill sets. I was worried I would find it difficult to be good at everything under the EM roof. I wanted answers and ended up back at Mark’s blog post, but have frustratingly (and amusingly) found more questions.

Since signing up to ACEM as a trainee I’ve been an ultrasound enthusiast. But after some embarrassing over-calls (and probably a host of undercalls I’m oblivious of), with varying degrees of consequence, I decided to put my money where my mouth was and pay for an expensive university qualification in clinical ultrasound. As a result, I’ve aged prematurely… within a very short space of time I turned into the old curmudgeon grumbling about young enthusiasts who pick up the probe because they know where the “ON” button.

Critical care ultrasound seems to be an invaluable tool for providing patients with the best care during their moments of physiologic crisis. Unfortunately it’s not necessarily as simple as eFAST, EGLS or HI-MAP. Sure, for most of our “sick” patients it will be adequate, but if we really want to walk the walk of a critical care clinician we should probably develop more robust resuscitation strategies than giving 2L of CSL, intubating and starting a noradrenaline infusion +/- antibiotics.

To develop that kind of skill set whilst wielding a sector probe, it would take time, practice, and departmental structures that foster accountability and quality control/improvement. That being the case, how does the RAT doctor get time to practice diagnosing the viral myocarditis with fever? Or the short stay/fast track doctor practice their carotid VTIs after a passive leg raise? Should we trust the ultrasound guru who can get a good A4C view in the 200kg ventilated patient to always recognise the posterior fossa stroke in a patient with vertigo? I am not convinced these dilemmas are simply a matter of more education or a broader training curriculum. For me, as soon as I begin to become better at a particular skill, my ability in other advanced skills invariably starts to attenuate. So what kind of an EP should we try to train? And again, what model of emergency care do we want?

I agree with Mark – there just isn’t enough emergency critical care work to go around for everyone. Is there enough for EPs to keep their skills up? Is the critical care we provide “good enough” for the people who do roll through the door in compromised states, or should we leave it to the intensivists?

Most of the time our ED critical care is great. I think there are times when we can do better, however, and in the future it’s possible we may see the evolution of a more hybrid emergency department faculty to further improve patient care. FACEMs could bring to their departments different skill sets such as advanced echo skills, paediatrics, ongoing care provision, administration and logistics. They would be supported by having time to maintain their unique skill sets (possibly/probably outside of the ED), and operate as co-operative cogs in the day-to-day departmental sprocket, rather than trying to be an overheating dynamo aspiring to be excellent at everything for everyone. The ideal model won’t land in our laps, and it will be important to experiment with various styles and structures of care provision if we are to get there. Even if attempts to mix up the structural status quo fail, they’ll still be hopefully leading us closer to our wait-free ED shangri-las where patients are safe, staff are happy, and care is cutting edge but sensible. (And patients with acute ischaemic strokes are not thrombolysed except as part of ongoing randomised trials to identify the subset of patients who might actually benefit from the therapy.)

For the record, my ideal near future job would be 0.1 rotating to other units doing some sort of meaningful clinical work and building relationships with other departments, 0.3 critical care EP, 0.2 needle in haystack EP, 0.3 teaching EP, and 0.1 running the floor, boosting morale and talking trash in the fishbowl EP. If anyone’s advertising such a position in a few years time…

Postscript (in relation to “Where to for EM?”):
1) hospital gowns are rubbish. If there are any aspiring tailors out there with a new design of garment for patients to wear, get in touch because you’ve got three investors – thanks CK for the idea (however for the needle-in-haystack patients, their own clothes are probably fine)

2) I do not know how to stop the insanity of frequent obs other than through a culture of education and encouraging clinicians (doctors and nurses) to think sensibly. It isn’t just clinical observations/vital signs though: there is something seriously rotten in the house of medicine when you discover interns and HMOs filling out limitation of treatment/resus forms for toddlers and teenagers because there is a tick box on the generic admission form asking if it is done… (no solutions there sorry, only stones to throw)

Director’s Corner: Culture

Today, another installment of Director’s corner, from Diana Badcock, soon to be appearing at a major conference near you (if you live in Dublin).

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When healthcare professionals are asked to consider the culture of health many offer that they are trying to “Make a Difference” by providing a lifetime of “Service” for the greater good of humanity and rate themselves as being trustworthy, acting with integrity, working in teams, committed to and passionate about the cause.

In reality surveys performed by health services in many hospitals in the developed world have us sitting with “BLAME” as our culture. A very immature and unsatisfactory state of affairs.

Blame stems from holding an individual responsible for a negative outcome rather than the system and processes that support the group/team where the event occurred.

Gratitude ( thank you ) and apology ( sorry ) is rarely uttered in cultures consumed with blame as they are driven by people who look after “number one”. Its rare for people to acknowledge responsibility or regret. If you live in a world of blame these words destroy self-worth and credibility.

Every system is perfectly designed to get the results it gets.

Lets fight this system- Buck a trend. The ability to utter these two words with care and kindness can move mountains.

It is hard for any one of us to change the system but we can change ourselves. Consider sharing and voicing ‘facts” that concern you, without judgement, opinion, exaggeration and emotion. Do not use tools such as “recruitment’ where you share your story with all these accouterments to create a team of us against them. This splits teams into factions and damages everyone.

Never make things personal.

What doesn’t kill you will make you stronger. Thankyou………….

EDCentral Exam Prep Page

Check out EDCentral education page for loads of ACEM Primary exam prep material, ACEM Fellowship exam prep material, links to important papers in EM and FOAM links that I like.

Parts of it (the primary section and the FOAM links) are bursting with goodness. Other parts are still growing so forgive us if some of it looks a little “under construction”

Much of the material is curated from elsewhere including from the ACEM DEMT network.

We owe particular thanks to Brendan Whiting (almost FACEM) for generating a large number of very high quality OSCES. All his start with the letters BW. Look out for them.

If there is stuff on here that you generated and did not want publicly shared in this way please do let me know. I have endeavoured to ensure that anything there was shared originally with the intention of making it widely available but the material is growing so fast it is hard to keep track of everything.

Timing and Choices

For this blog post I am thrilled to introduce a new EDCentral author, the Director of the Bendigo ED, Associate Professor Diana Badcock.
I am hoping this will be a regular thing and that I might even get her trained up in wordpress use herself but for the time being I am posting it on her behalf.

ED Directors Corner

Diana Badcock

‘Timing and Choices’ was an expression a good friend’s father would hail along with “When the gorse is in bloom, its time gorsefor love’. Given gorse is in flower 365 days of the year in Scotland he was clearly a romantic, but “timing and choices”? Was this a life lesson relating to success?

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In the Emergency Department time is of the essence in so much of what we do. The “Golden Hour” of trauma, “time to antibiotics” , “door to balloon” time, plus our hospital KPI’s (Key Performance Indicators) and NEAT (National Emergency Access) Targets are ways of measuring the success of us all, as clinicians and of the processes we work with. We drive, and teach emergency trainees to be a ‘reflex arc”. To recognise a pattern of disease and act accordingly.

Speed is of the essence.

How does this then affect our behaviour in other areas? And can it do harm?

In relationships, at home and at work, so often we would be far better to “slow down, to speed up”.

If we could hold our thoughts, tongues and behaviours at times of great activity, stress and anxiety (ours and our colleagues), discussion and debate in the Emergency Room could be less disruptive. This is beneficial in delivering safe and quality patient care, and also improving staff satisfaction at work.

CHOICES

venEducation in health traditionally focuses on improving scientific knowledge.

Increasingly discussion around human intellect informs us that general
intelligence has been surpassed with the more intelligent of us connecting emotionally, and with curiosity.

To survive in health (or maybe for healthcare, as we know it, to survive), we must be curious and educate ourselves more widely. There is a need to understand politics, governance, the business of health, our college, the training system, the constraints of our systems and prior learnings from elsewhere and other industries. It is paramount to stay connected to everyone you meet, personally or professionally, and when at all possible for them to recall you favourably. The receptionist for the job interview will open doors in more ways than one. Treat everyone equally, acknowledge them and give them time. It will be these relationships you forge that create a network of choices later.

As Director of a busy emergency department most issues I deal with relate to dissatisfaction with human factors and system processes. Rarely are complaints around lack of knowledge.
Clinicians need to drive maximising value in health and become pro-active thinkers who dissect and analyse the system. We need to be then prepared to assist in re-engineering and rebuilding a sustainable healthcare system. Choices everywhere.

We need to get savvy with the ‘fluffy bunny’ side of leadership and start with caring for ourselves and each other.

Culture is coming next time, then process thinking…

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#FOAMed – is it all just froth!!

@cianmcdermott

In recent years, I have become very interested in #FOAMed. Too interested sometimes!

I am still amazed by the amount of people that do not use FOAMed to stay up to date. For this reason, I hope that this post will help you with the nuts and bolts of Twitter/ FOAMed. Please read on…

What is #FOAMed? Why should I use it?

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I hear so many reasons why we as doctors should not bother to use SoMe:

  • I don’t have the time
  • Its all a lot of nonsense – who cares anyway
  • My kids use it – I’m too old for it!

But Twitter can be a really useful resource to engage with.

What is it all about?

FOAMed stands for Free Open Access Medical Education. Simply put it is a collection of blogs and podcasts that is available online for anyone, anywhere to access. It is It is a decentralised, free, cloud-sourced, movement that has exploded since its introduction in 2012.

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Tell me about Twitter?

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Twitter is an online microblogging site. It is the main platform that is used to link all our online conversations together and allows a community of critical care physicians to connect together and post links, share ideas etc.

The FOAMed hashtag (#FOAMed) is a method of grouping together all social media conversations on twitter.

So FOAM is the concept, FOAMed is the conversation while #FOAMed is the hashtag that you use to search on Twitter.

What are the benefits?

FOAMed facilitates asynchronous learning via a flipped classroom environment. #FOAMed is a medium rather than an entirely novel system and it should integrate with traditional teaching methods.

At weekly registrar teaching, say we are going to learn about ED Procedural Sedation. You are away on leave but keen to join the conversation. You can pre read teaching material beforehand and then review the presentations afterwards. Now translate this idea to a world wide audience. The possibilities are limitless!

What are the drawbacks?

Without doubt, there is a lot of material out there! How do I know what to trust? Yes at times, it is intimidating to see all the commentaries on Twitter. I mean everyone just cannot be right? But everyone has a voice. It’s known as ‘drinking from the firehose’.

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In my experience, the cream always rises to the top. Twitter encourages an online peer-review process as soon as something goes live. So the really good material will be reposted, referenced, retweeted until it finds it’s way to you. However, you still need to examine the evidence, think about it, read the original paper and then listen to other people’s opinions as part of a community. This is after you read all the conventional wisdom from textbooks.

OK, I’m interested. How do I start?

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Start with a Twitter account. Choose a username and write  a 3 line bio about yourself and maybe even upload a picture. Another few tips:

  • Dip your toes in – see how you like it
  • Follow topics that you like
  • Follow people who share your interests

But I want to go to #smaccDUB!

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The 2000 delegate tickets have been sold out for months. #smaccDUB will be one of the most eagerly-anticipated medical conferences yet. It takes place in Dublin, Ireland from June 13th to 16th and it will be truly AWESOME and AMAZING!

Don’t worry though, by the power of Twitter and FOAMed you can follow all of the action. Check out smacc.net.au and stay in touch with the ground-breaking talks from where ever you live. You can even catch up with the social night but it’s just not the same as being there! Never mind there’s always next year….

So follow my updates from #smaccDUB, I will be active on Twitter @cianmcdermott. Diana Badcock is speaking on the opening morning, follow her @djbdjm. Remember #smaccDUB is the hashtag!

A final thought…

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Join the community

@cianmcdermott

A new use for the RIC

I sometimes work in departments other than my home shop. One of the problems I often encounter is needing to do procedures with kit that I’m unfamiliar with.

The most recent situation involved doing an ascitic tap. The shop I was working at didn’t have any angiocaths or dedicated paracentesis kits suitable for a timely therapeutic tap. A central line might have done the trick, but  have made the frustrating mistake of using a CVC to drain a pleural effusion once; resistance make drainage agonisingly slow.  The patient was obese as well as ascites-laden and the longest cannula I could find was 32mm – enough to penetrate the peritoneum (just!) but not long enough to reliably facilitate drainage without outward migration.

In the end what I did was wire the cannula and insert a rapid infusion catheter. With its build-in dilator/stiffener it got into the peritoneal cavity easily and drained the ascites at a very respectable rate.  The patient found it very comfortable although the hole it left was a bit leaky for a short time afterwards.

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I can’t swallow it!!

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In keeping with the Christmas season of all things food-related – what do you use for oesophageal food bolus impaction in ED? Maybe Coca-Cola™ or buscopan or what about IV glucagon? Do any of these really work or should your patient be on the next endoscopy list? A recent EMJ Best Bet examines the evidence for intravenous glucagon in the treatment of oesophageal food bolus obstruction (FBO)

 

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Research says  – not enough high quality evidence to support the routine use of IV glucagon in oesophageal FBO BUT

Clinical bottom line:

  • Glucagon IV may be reasonable to use in FBO – it may not work if there is an underlying oesophageal structural abnormality
  • It may be successful in about 1/3 patients or it may not work at all in which case endoscopy is recommended
  • Less likely to work if meat is the obstructing agent
  • Optimal dose is 0.5mg IV, higher doses are no more effective and may cause unwanted side effects such as vomiting
  • In an older patient with a meat FBO, consider gastroscopy early

Author’s opinion – give it a go (in certain patients) but realise that it may not work and have a back up plan ready