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?

TIMING

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…

#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

Where to for Emergency Medicine? What model of care do we want?

I am always left a bit flummoxed by exhortations to dream up a new model of care for the ED. I feel as though the person doing the exhorting has some specific image in their head that they are hoping everyone else might share but I can never quite work out what it is.

The traditional model that I grew up into was that people decided what constituted an emergency themselves and either called an Ambulance or walked in to the ED and the triage system rewarded those who had what we agreed was an emergency by giving them prompt treatment, while punishing those who we disagreed with by banishing them to the waiting room. As demand went up it became normal for those banished to the waiting room to wait for 4, 5 or 6 hours, with stories of people waiting 24 hours to be treated being possibly true or possibly urban myth.Then we started to get the patients who even we thought had an emergency waiting hours. Bed block bypass, ambulance ramping. Something wasn’t working.

It wasn’t long before that started getting taken apart though. Part-way through my second post-grad year the Victorian trauma system was born. Along with the redirection of most of the trauma to the major trauma services, it was also heralded the arrival of the formal trauma team model in our urban district emergency department. Suddenly, while an ATS category 2 stroke or chest pain could theoretically wait 10 minutes to be seen (and would sometimes wait much longer unfortunately), a Cat 2 trauma was being seen by a multidisciplinary team immediately.

Then came the fast-track. My training hospital was already running an “Acute Care” side and an “Injury Clinic” side reasonably successfully. Fast Track took this idea into a lot more EDs. There is no doubt that Fast Track eases the waiting room and allows efficient care to be provided to the kind of people who are hard to take care of outside the ED (cut, sprained and broken things that need some imaging and a simple fix) but it also has the potential to prioritise the sore finger over the septic abdomen simply because the Fast Track side of the ED is actually flowing and the main side is blocked up.

Now we have Code Stroke, Code STEMI, Trauma, Sepsis, Neonates all competing for immediate care. What’s more, nobody else wants to wait to be seen either. People are talking about the wait-free-ED. A previous Prime Minister of Australia decided that no patient should stay in ED longer than 4 hours and although that is about the length of time an Australian Prime Minister currently stays in office, the 4 hour rule has stuck, for better or for worse. Short stay units, acute medical units, clinical decision making units have all changed the way we move patients out of the department.

And the patients still wait too long to be seen.

There are a lot of EDs in the US and Australia that have attempted to get rid of their waiting rooms and that have created discharge lounges and results lounges and various similar spaces, attempting to shift the waiting process to the end of the stay rather than the beginning. I have seen a lot where the results/discharge lounges are being used for equipment storage and they have stuck temporary seating in next to triage to accommodate the waiting patients now that there is no waiting room. In others, the resus patients are sieved off to one side and the fast track patients sieved off to the other. The remainder are seen at the front door by a team lead by a (frequently disgruntled) emergency physician and then… well they wait of course. Because these remain the bulk of the patients. The fact that we have sieved off all the easy ones into categories with individual names doesn’t change the fact that the undifferentiated maybe-sick-maybe-not patient is the bulk of the ED census. They are also the bulk of the hospital admissions.

So does this mean the only way to see everyone straight away is for the EP to run faster? Because that doesn’t sound like innovation to me.

In order to try and rebuild the way we practice emergency medicine we really need to think about what the role of the ED is and what we want our specialty to do. We definitely need to do more than demolish the waiting room.

Why do we need EDs?

First of all, we would all agree that the community needs a place where critically ill patients can be rescued at any time of the day or night, every day of the year, by doctors and nurses experienced in resuscitation.

Resus however is not really why Emergency Medicine was born. Essentially EM came to be because there were patients who either needed to be admitted to the hospital acutely, or who were worried that they might need to be, and the way these patients were being treated was an embarrassment and medico-legal liability for the hospital. Junior doctors, inadequate equipment, poor supervision were the standard way to access the hospital system if you became ill or injured in such a way that you weren’t able to come via an experienced doctor’s rooms.

Since establishing the role of EM as a gateway to the hospital for unscheduled care, and as a resuscitation unit, the mission has progressively expanded, to providing a form of acute primary care for ambulant patients, acute psychiatric care, a screening service for all acute hospital admissions even those coming from the rooms of the admitting physician, a minor injuries service, a second opinion service, a proxy outpatients service and so on.

What do we want an Emergency Physician to be?

Here are some ideas that I have about how we might rejig our work, based around the different faces of the FACEM community. I don’t really know how it would all operate, I just have some ideas about the different kinds of EM practice that might exist and ways that we might like to stream our patients along those lines to get the best for all of them.

The critical care EP

This FACEM would happily just run a 5 -10 bed resus room with 3 ED-ICU short stay beds and a 10 bed Short stay (nursed at 1:3 – 1:4 night and day) and never see a weak and dizzy or a back pain or a broken arm unless their FastTrack colleague was bringing them a broken arm patient to sedate/anaesthetise for a manipulation and plaster. They would see chest pain, sepsis, COPD, pneumonia, trauma, acute heads, and nothing much else. Running a no-wait system would be straightforward in this area. You need a registrar, an intern and a final year med student to run this unit and the EP, when nothing is happening, would be working on writing a paper about what a great job they’ve got.

There are some amongst us who would be very happy in this role and would be delighted for this to be the totality of Emergency Medicine. There are some troubles with this system however. First, there isn’t enough work for all the EPs out there. Second, there will be the problem of over and under triage. There is still going to need to be a place for all the people who don’t immediately seem like they belong in the ED-ICU but who might turn out that way, unless you want to really overtriage into the ED-ICU in which case you have just reproduced the current ED.

Which brings us to…

The needle in the haystack EP

This doc takes care of the biggest group of ED patients. These are the triage Category 3 and 4 patients, none of whom have simple binary questions to answer and many of whom end up needing admission to hospital.

This EP’s main tool with a critically ill patient is the ability to recognise them and send them to the right place. Their greater strength is in taking care of all the weak, wobbly, tired, dizzy, frightened, puffy ankled, short of breath, belly aching, more confused that usual, pregnant and bleeding, muddled-up-my-tablets patients that occupy the the mass of our cubicles away from resus. They can make people feel listened to and cared for and can find the sick patients without putting the whole ED census through a CT scanner.

Running a no-wait system for the needle in the haystack EP’s patients is a very challenging notion. The problems they present with do not truly justify no-wait; providing a top notch no-wait service for them is potentially taking business away from the GPs (and in Australia, where the government runs the hospitals but the GPs are operating in a private practice model, there are issues with “big government” stealing customers from “the little guy”). The better this service is the more it will creep into less and less emergent problems because people will choose it over the GP who costs money and can’t get everything done on site in one visit.

A more efficient system for these patients could start with patients not owning a bed but lying down for a purpose. It is mad that someone who is not incapacitated should be tucked up in bed in the middle of the day while a sick person doesn’t see a doctor for lack of somewhere to be seen. So get the patient into a gown and onto a trolley. Take the story and examine them, get the ECG, bloods and imaging.Then get them out of their ED trolley and somewhere else and free up the acute assessment space for someone else.

These are the patients who might be more efficiently managed using a results lounge or discharge lounge or some arm chairs. The Needle in the haystack EP needs to use their beds like a consultation space, to speak to and examine patients and then stream them to somewhere else (straight home, SSOU- like area, resus-critical care area). The needle in a haystack EP probably needs a different sort of SSOU from the critcare EP.

What are the barriers to these systems being used?

Patient gowns
Once you are in a gown you want to be in a bed because otherwise the world can see your arse. We need to rethink how we dress/undress our patients if we want to use a “return to waiting room” strategy. Surely we can do better than those awful gowns.
IVs:
We probably place a lot of unnecessary IVs and we give a lot of unecessary IV fluid but having an IV up will stop someone moving out of their trolley. If there is a need to use IV therapy or meds in a non-critical care environment we should probably stream those patients off to a short stay unit (although the fact that people can have IV infusions of horrendous poisons whilst sitting in armchairs in day oncology suggests that we don’t strictly need a patient to be lying on a trolley just to have an IV medication.
Monitoring:
Don’t we just love monitoring? And don’t the patients hate it, especially the horrible NIBP cuff that brutalises their arm every 15 minutes. We need to think more rationally about monitoring. The patients requiring ongoing monitoring and obs should be streamed into the resus-critcare ED or the SSOU.
Patients are tricky:
As much as we make a thing of EPs being able to make a split second decision and predict where the patient is going, the truth is that only works most of the time. We still get screwed often enough that the quick look/superficial front door assessment can get us into trouble. The primary care EP is most at risk from this because they treat the large numbers of haystack patients. The patients triaged to the critical care ED are assumed to be sick so the critcare EP starts by throwing everything at them and gradually trims back. The patients in the primary care ED are assumed to be not so sick and so will catch us out sometimes. There needs to be a good system for moving back from SSOU if things are not right with these patients without it being punitive. It needs to be accepted that we are putting some patients into SSOU in order to let them declare themselves as sick or well.

The bumps and breaks EP:

Fast track is working pretty well for us. There are lots of models that work well with this. In the US is is almost all run by Nurse Practitioners and Physician’s Assistants. At our place it is supervised by a FACEM or registrar but the bulk of the work falls to the intern and physiotherapist (and our one and only NP when she is on shift). I like the idea of medical involvement in FT as it provides a good training ground in surgical and orthopedic skills and it can be satisfying work. It seems a shame to hand it all over to another profession.

The ongoing care EP:

There are some of us who really enjoy the ongoing care side of medicine and are a bit misplaced in the 4 hour ED. We need to think about how to keep a role for ourselves in the 4 hour rule world. I think we need to look at what we are good at: decision making, working with different people, coordinating and keeping up a good tempo of work at 24/7/365. As the 4 hour rule shrinks the Emergency Physician’s domain, the EP needs to look at new territories to conquer.

Departments of Emergency Medicine need to look hard at whether they could take over Hospital in the Home, “frequent flyer programs” (HARP in Victoria), Residential Care In-reach programs and Telemedicine programs. Innovative staffing solutions including nurse practitioners, paramedics, physician home visits should all be considered. In Montreal, I am told, it is common for family medicine residents to share an oncall service for assessment of nursing home patients, a centre in Pittsburgh is using paramedics to do home visits for their admission reduction program, in Bendigo we use an experienced nurse who can consult with the Geriatrician and Emergency Physician on call, to do nursing home visits and to support their staff with acutely unwell patients.

Further than this, EM should be looking at whether we are the people to run clinical decision making units, acute medical units, even acute surgical assessment units. These would be a big reach from where we currently sit but I don’t believe they are out of our reach. Our tempo of work suits these units. Taking our skills into these units would mean that we were not taking patients who really needed the attention of an EP and sending them prematurely on to an internal medicine physician or a surgeon just to satisfy a mandate to get patients off ED trolleys in 4 hours.

It is likely that a shared care model would be required. The ultimate decision on a surgical decision making unit is when to take a patient to the operating theatre, a decision which is the domain of someone who will be operating on them.Acute medical units, while mostly managing common conditions in a fairly standard way, are a place that the more esoteric diagnoses need to be explored, and the complexities of interacting comorbidities carefully considered. This is the domain of the internal medicine physician.

In each of these units, an EP could  use their expertise in managing the flow of patients and coordination of care, and applying their familiarity with rapid turnaround times and frequent revision of plans, hand in hand with the surgeon or physician (internist).

This kind of sharing of expertise is something I believe we are getting better and better at due to growing experience in the resus room as team leaders. In Australia, the UK and parts of Canada it is common for the EP to team lead trauma resuscitation with a trauma surgeon in attendance for their specific surgical expertise (this happens less in the US where trauma surgeons spend a third of their life as intensivists and tend to combine the jobs of resuscitationist and surgeon). In our hospital we are working hard on taking a similar approach to Neonatal Resuscitation, this time sharing care with the general paediatritian (we have no neonatologists in regional Australia). Anyone who has done a pre-hospital physician role will be familiar with the process of sharing care and expertise with an intensive care paramedic. As we all get better at understanding that we are all working to the same end we (we being the health care provider world in general) we will get better and better a this process.

The front door EP

I don’t even want to talk about the front door job. I think we made a big mistake by stressing that we can usually make a decision in a few minutes because now there are places that are expecting us to do that, accurately, every few minutes for a 9 hours shift, with no ongoing connection with the patient and no chance to get feedback on those decisions. I am yet to meet an EP who, when asked about the front door role, doesn’t roll their eyes and groan (except a few directors who speak expansively about the wonderful effects on ED wait times).

In summary

Emergency Medicine has come so far since its birth in the 1960s, too far for us to allow it to be defined out of existence by changes to KPIs from above. Luckily for Emergency Medicine, we remain a new specialty which means optimism, agility and a preparedness to adapt and develop. What we need is passionate and imaginative Emergency Medicine innovators prepared to try new things to get good results for our patients and the community and to further develop our specialty.

We are not short on such people.

Severe croup- a short post

A little while ago, there was a little 15mo old, brought in by petrified parents, appearing to be peri-arrest  with severe croup. How severe? His eyes were rolling back, his belly was flopping in badly (I had never seen the belly working this hard), the colour of his skin was… next time you walk in the resus – look at the floor – that was the colour of his skin. The only noise he was making on inspiration was a high pitched squeal… He probably had less than a dozen breaths left in him…

Out came adrenaline with the neb… Literally 5 breaths later you could see that the tide had turned… From there on it was a breeze… Two hours later you could not tell this child was nearly dead when he came in.

Two points I made from this case:

It seemed it took an eternity for adrenaline to happen. There were five 1mL ampoules of 1:1000 to open which took probably around 45sec which feels like a really long time watching a child in extremis. We could probably chuck one ampoule in and start the neb, while the rest of the concoction is being prepared. This would save those agonising seconds of not being able to provide the much needed drug while waiting for the whole enchilada to to arrive. Here’s the catch with that though. The residual volume of a nebuliser device is betwen 0.5 and 1mL so you then need to add a few mL of Saline to your 1mL of 1:1000.

Giving parenteral steroids is another hurdle. The RCH CPG recommends oral steroids for mild croup but parenteral steroids for severe and in much bigger doses. [Editor’s note: As we know, steroids are very well absorbed orally and the onset of action is so slow that the difference between oral and parenteral administration is minimal, MP]. For the sake of saving the child from another distress and detirioration, I think this could be given orally, just squirted into the mouth once the dust is more or less settled (usually within the next 5-10min). Even with a most non-cooperative child, I found if I put medication in standard syringe, attach an IV canula to it and get the parents or the nurse to sneakily slip it into the mouth and drip it in drop by drop… I found this way I can even get as much as 10mL volume in a most non-cooperative child within max 5min instead of blasting it in and having it back on my or parent’s chest.