Redthread Part One

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It was great when Freya, David and Richard from the Redthread team at the QMC Emergency Department came down to record the first of three podcasts with us.  

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Redthread is a charity working with young people to help them lead happy, healthy and safe lives.  Key to this is the teachable moment, the moment a young person is in an Emergency Department and can be shown the way to turn their life around.  Since starting in London over 20 years ago they have since expanded into Nottingham and now Birmingham too!

In this episode the team tell us about their own backgrounds, how they came to Redthread and how Redthread came up to Nottingham.  They then take us through their day-to-day work and the help they can offer vulnerable young people.  There's advice along the way as well as chat about Curlywurlies!  

For more information visit the Redthread website 

ACPs in ED

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In this special episode Senior ACP James Pratt joined the podcast to talk about Advanced Clinical Practitioners in ED.  This is a topic he's talked about before at various conferences and meetings.  At EM2C 2018 he started his talk rather impressively:

James and Jamie talk about:

  • What is an ACP and what their job role entails
  • James' own career and the development of the ACP team at the QMC Nottingham
  • What the Nottingham ACP course consists of and the course entry criteria
  • Issues in the development of the ACP team and how these were approached
  • Potential areas of future development
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There's an emphasis on the education and time required to create the ACP service and how this is not a short term solution to staffing issues but rather a long term investment in our staff

For more information on the ACP course at the University of Nottingham you can visit the course page here

For more information on Advanced Clinical Practitioner Educators you can visit the Association of Advanced Clinical Practitioner Educators website here

We're looking make more podcasts on advanced practice in the future so please get in touch with any suggestions!

P Cubed (How to do a Presentation) - #wewillgiveDREEAMpresentations

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In a previous blog post I've already sung the praises of Ross Fisher and the p cubed approach to presentations.

In this live recording at the latest DREEAM educators' meeting I talk a bit more about p cubed, how to present information in a way that's not just nice to look but has science behind it.

Here are the slides.  As ever just click to scroll through them.

Topics covered:

  • Why bullet points are bad (irony)
  • How to storyboard - spark points and lightning slides
  • The science of presentations - cognitive overload, the three second rule, the rule of thirds and dual coding
  • How to present data

Here is the Take Visually for this episode: 

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I hope you enjoy this talk and feel inspired.  That's the purpose of this talk and as a team at DREEAM we have made a Twitter pledge #wewillgiveDREEAMpresentations.

For more information on learning theories (and why it's wrong to think about 'types' of learners) check out Learning Scientists.

Good luck telling people of the amazing things you've seen.

                 - Jamie

 

ABCDE of Chest X-Ray - Use the RIPE Approach!

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In this podcast Dr. Harry Pick, Respiratory Registrar and Clinical Research Fellow at Nottingham University Hospitals NHS Trust came down to talk us through Chest X-ray Interpretation; a key skill in the Emergency Department!

Harry very kindly gave us a copy of the Powerpoint he uses when he teaches this topic; due to confidentiality reasons these slides don't have X-rays on them but great resources can be found at Radiology Masterclass. Click either side of the pictures to move through them.  

Remember the step by step approach:

Right patient; day and time? - this is key for all investigations.

Is the film AP (anterior to posterior) or PA (posterior to anterior).  This matters for two reasons.  Firstly, an AP film tends to be an portable CXR and so tells you that the patient was sick when it was taken, this may be confirmed by the presence of chest leads, O2 tubes and central lines on the film.  Secondly AP films exaggerate the size of the heart and so you cannot comment on cardiomegaly.  You can on a PA film.  In a healthy individual the heart should be no more than 50% of the thoracic width on a PA film.  If the scapulae are not projected into the chest assume it is a PA film.  It should always say if it is an AP film.   

'RIPE' - Rotation (equal space between medial aspects of clavicles to spinous processes), Inspiration (>7 anterior and 9 posterior ribs, Picture (can you see everything you want to see?) and Exposure (can you see vertebral bodies behind the heart).

Then remember ABCDE - this varies - the Take Visually below follows Airway, Breathing, Circulation, Diaphragm and Everything else.

Harry's ABCDE covers the same things but in a different order - Apices, Behind the heart, Cardiophrenic and Costophrenic angles, Diaphragms - above and below and Everything else. 

Don't forget to compare the chest x-ray with any previous ones (very easy on most programmes) - this is very useful to assess any acute changes.  Older x-rays should also have been reported which will help your interpretation!  

As you can see there's a subtle variation, make sure you find a method that works for you!  

Here is the Take Visually for this podcast.  

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Geeky Medics have a great page on the subject as well.

Focused Trauma Conference 2017: Deel Drie

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In the third part of the day we focused on balloons, namely REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) - the Life in the Fast Lane post can be found here.  The talk was by @emeddoc.  This procedure is intended for cases of non-compressible traumatic haemorrhage.  Before REBOA the best possible method to achieve haemostasis was through compressing the descending aorta via resuscitative thoracotomy (RT).  Data from the American Association for the Surgery of Trauma (AAST) in 2014 shows that REBOA is at least non-inferior to RT.  In trauma patients in LOST (ie not TCA yet) who required REBOA 92.6% survived their stay in ED and 22.2% survived to discharge.  Increasingly work has shown REBOA to be feasible in the pre-hospital setting and has the best survival rates if performed pre-hospital.  

However, a study from Japan showed that REBOA is associated with an increase of 16.5% in mortality.  However, the median door to surgery time was 97 minutes and further research has shown in animal studies that lactate clearance is intact 45-60 minutes post REBOA but after that the ischaemia distal to the balloon may be irreparable hence the poor date from Japan. This raises the possible of future research into partial inflation to not completely cut off distal flow and have some permissive hypotension.  

REBOA is not just for the pre-hospital medics to be concerned about; it requires clear handover to the hospital and theatre teams after it is used as it will alter physiology.  It it there to buy time for the definitive surgery and it was emphasised several times that any unit wanting to implement REBOA will require widespread organisation and culture change.  

Here is the Take Visually graphic for this podcast and blog:

It was a brilliant and interesting day; thank you to all the organisers.  Antwerp is a lovely city and the Belgian people were very welcoming; if you can visit do!

Focused Trauma Conference 2017: Deel Twee

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In the second part of the Focused Trauma Conference we were treated to a focus on the role of ultrasound and clam shell thoracostomy.

Dr Jim Connolly (@jiconnoly) kicked off the second part by imagining a post-stethoscope world (Stethxit) and instead where we all have hand held ultrasound devices - a reality that's closer than we think - he believes once they crack a cost of <£1000 (i.e. the cost of the new iPhone) a unit we will all have one! POCUS will help identify the majority of causes in cardiac arrest (pretty much all of 4Hs and 4Ts apart from hypothermia or toxins).  POCUS reduces the time to operation, the number of CT scans and even the length of stay in hospital.  It is time critical, helps with Bayesian reasoning and with answering Yes/No answers.  It is more sensitive than auscultation and x-ray in detecting pneumothorax and takes a quarter of the time that CXR does.  However it is important to remember its limits:

  • A FAST scan needs about 500ml blood in the abdomen to pick up - "you need blood to bleed" and so there may be false negatives
  • It changes nothing in penetrating TCA

However in blunt TCA it is useful to pick up cardiac standstill (a very poor prognosis) and also to distinguish pseudo from real PEA.

It was then onto thoracostomy with Professor Lockey and then Dr Connolly again.  The procedure was first performed in 1988 and provides better visualisation than the left lateral approach.  Professor Lockey talked about the approach in 'street thoracostomy' often performed in cases of stabbings and even terrorism:

  1. Open the pericardium
  2. Seal the hole (ideally a single hole in the right ventricle) - occlude with a finger, stitch or staple it or use foley catheter
  3. Restart the heart - flick it, volume load, 2 handed massage, ventricular adrenaline, given bicarbonate (usually young people getting stabbed so should be fine) and calcium
  4. Clip the internal mammary arteries and clamp aorta and hilar
  5. If the patient wakes during anaesthetise with Midazolam 1mg and Ketamine 30mg
  6. Forensic awareness is also important in cases of stabbings 

The whole procedure should take less than 2 minutes.  It is not to be performed in cases of shootings/high energy transfer, if the heart is empty or if the TCA has been prolonged.

Dr Connolly reinforced many of these messages as well as emphasising that the biggest barrier to before the clamshell is the fear of being criticised.  It is a procedure not an operation designed to achieve damage control and restore physiology NOT anatomy.  It is to be performed in witnessed TCA or if there were very recent signs of life or if the systolic BP is <70mmHg despite fluid resuscitation.  The wound most likely to survive is a wound to the right ventricle with a tamponade.  When suturing a horizontal mattress suture is least likely to occlude the coronaries.  He also emphasised the importance of training - at times of stress we revert to our lowest level of training.  There are other considerations to have - once output is restored the patient needs to go straight to theatre and can have only vertical sliding not horizontal.  

Here are the Take Visually graphics for this podcast:

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Focused Trauma Conference 2017: Deel Een

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It was great to attend the inaugural Focused Trauma Conference hosted at the University of Antwerp.  Although run with a Belgian slant on things there were a number of British speakers and the whole event was in English which was useful for my dotard ears as one of the few uni-linguists in the audience.  The venue was amazing.  

Thanks to the breaks the day roughly broke up into three sections with different topics explored.  So, like the aorta in REBOA, (more of that later) we will tackle the day in three parts.  

In the first part Professor Nijs began by exploring major trauma in Belgium.  Belgium has twice the mortality rate due to trauma of the UK and has no system of Quality Assurance.  I was really proud to be part of the NHS as he highlighted the improvements seen in the UK since the MTC network was set up.  Whilst he pointed out that all systems need a 5 year maturation period in the UK we had seen immediate improvements in outcomes which increased year on year.  Major Trauma is an area of constantly changing paradigms: we no longer consider traumatic cardiac arrest a futile endeavour and there are ever improving methods of haemorrhage control such as REBOA.  He feels Belgium should aspire to the UK model but they will need:

    1.    The resources

    2.    People who understand

    3.    People who have the skills

Dr Ed Barnard (@edbarn) then spoke about traumatic cardiac arrest (TCA).  There is no universal definition of traumatic cardiac arrest which makes research difficult but this is predominately a disease of young people. Whilst initial papers gave low survival rates recent Trauma Audit and Research Network (TARN) data from 2009-2015 shows a 7.5% survival to hospital discharge rate as well a 2/3 moderate to good neurological outcome post TCA.  He discussed methods of public engagement as well as distinguishing between low output states in trauma (LOST) and no output states in trauma (NOST).  Whilst the standard methods of controlling bleeding and IV filling may work in LOST the future of resuscitation in NOST may involve methods of controlling and providing flow such as selective aortic arch perfusion.

In the final talk of part one discussed the European Resus Council (ERC) algorithm for TCA,

Universal cardiac arrest algorithms are not suitable for TCA as they can result in delays of nearly 10 minutes whilst looking for a reversible cause such as tension pneumothorax.  The ERC algorithm places chest compressions at a lower priority in TCA than treating hypoxia, tension pneumothorax, tamponade and hypovolaemia.  Dr Truhlar (@TruhlarA) openly admitted that the role of CPR is unknown.

The only nation to reject the ERC guidelines was the UK (insert Brexit reference) with the UK Resus Council producing its own guidelines as above which keeps thoracostomy and needle decompression as considerations not standard practice for all TCA.  

Dr Monsieurs (@kmonsieurs) continued this debate of the role of chest compressions in TCA.  He felt that maybe chest compressions provide little benefit in TCA and get in the way of other things which provide much more benefit.  There was discussion about how hard it can be for a professional to stop CPR for other procedures once bystanders have been doing compressions after calling for help.  Dr. Barnard made the interesting point that chest compressions whilst improving systolic BP cause diastolic BP to drop and so reduce coronary perfusion.  

I think the role of chest compressions in TCA and the ERC and UK TCA algorithms will provide much more fuel for research in the years to come!  

Here's the Take Visually for this podcast: 

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We're All Going on a #FOAMed Holiday

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Take Aurally is once again on the move this time heading to the Belgian city of Antwerp to take in the refined air, culture and the Focused Trauma Conference  on 14th October. 

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For those not going worry not as we shall podcast from the conference (or a cafe near by) as well as present a Take Visually or three.  Remember to follow @takeaurally for all the goings on.  

Here's the full running order:

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The ED Pharmacist

Kunal Gohil, the ED Pharmacist at the QMC came down to discuss his role, the benefits, challenges and further developments. 

We talked about:

  • The training of a pharmacist in the UK
  • Kunal's background and how he came to work in the Emergency Department
  • His role and how it has developed
  • A normal day in the life of an ED Pharmacist 
  • The benefits to the department and trust
  • His work on time critical medication such as anti-Parkinson's 
  • Advice for other pharmacists and trusts interested in the role

Here is our Take Visually on the ED Pharmacist: 

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