Nearly at the end of what has been a fun and exciting conference with lots to learn and take home into our own practice. We’ve described much of this on our blogs reviewing Day 1 and Day 2. Day 3 was no exception and started off with two expert panels on acute coronary syndromes and troponin, and venous thromboembolism. These world experts, including our own Rick Body for the first panel, and Dan Horner for the second, discussed in detail recent advances in technology, risk scoring, and what clinicians are up to in their departments not just in the UK, or Europe, but also around the world. From the heart side, we heard about how limits of detection are helping us to develop assays to discharge low-risk chest pain at the front door, and about new biomarkers that may in the future be added to our troponin labs in order to better risk-stratify patients. It’s possible that we may see changes to risk scores such as the HEART score. One of the big difficulties in developing these tools is that there are many different troponin assays at the moment, and not all hospitals yet use highly-sensitive troponin, which are what new risk-stratification methods focus on. You need to know what your hospital uses first before you can develop pathways to manage your patients.
It’s important to remember that we often focus on ruling out ACS and breathing a sigh of relief when the troponin is negative, but that doesn’t mean your chest pain patient can just go home!
We've spoken a lot about ruling out MI, but just because you've done that doesn't mean you can send your patients with chest pain home! There are other important diagnoses you need to rule out too! @barbrabackus #EuSEM18— Chris Gray (@cgraydoc) September 11, 2018
Don’t forget about things like PE, pneumonia, aortic dissection, and pneumothorax. All serious pathologies to think about and rule out (even just clinically). If you’re a junior doctor in ED, have a look at this blog and listen to the accompanying podcast by Simon and Iain that takes you through the key things you should know about chest pain.
Bernard Foëx is a legend around Virchester and his talks are always fantastic to listen to, so I couldn’t not mention his talk on risk stratification in domestic abuse. It’s an issue that affects over 2 million people a year in the emergency department, and there’s no doubt that at times victims (and sometimes perpetrators) end up in our care. We need to consider domestic abuse when things just don’t fit, the same as how we would consider non-accidental injury in children. It has to be at the back of our minds or we will miss it. The balance of confidentiality vs disclosure is difficult and can have a huge effect on the victim going forward. If they don’t want disclosure, point them towards key resources such as safelives.org.uk, and make sure they have an escape plan.
Global health and volunteering is something that a lot of junior doctors in emergency medicine are keen to get involved with and gain experience in working in cultures and societies outside of the UK and the NHS. It’s difficult to start as a lot of organisations want prior experience, but how are you meant to get that without joining an organisation? It’s a vicious cycle and often leads to doctors participating in something called voluntourism, travelling to other countries and approaching communities or local medical teams with offers of help, without the backing of a regulating body. A great panel of highly experienced global health and emergency medics, including Amy Hughes, Jennifer, and Teri Reynolds discussed how we can become more involved and the challenges that they themselves have faced and overcome. Try to talk to people who have already done what you want to do, get their advice, and learn from their experience before planning your own. The RCEM Global Emergency Medicine committee is committed to supporting RCEM members wishing to undertake global work, so get in touch with them too!
What does global health work make you good at:— RCEM Global Emergency Medicine (@RCEMGlobal) September 11, 2018
Ethics and human rights
Cultural awareness (becoming #woke)
Amy Hughes@EuropSocEM #EuSEM18
There were a lot of powerful talks on research on day 3 as well. Jason Kendall spoke on the experience of being a principal investigator, having won the RCEM PI award this year. He started with the story of an almost 20 year journey to bring intranasal diamorphine into the NHS. Jason is a bit of a legend and although he describes himself as an amateur academic, a full time clinician and a non-affiliated researcher, there is no doubt that his contributions have been substantial and he is proof that you don’t need a fancy title to be involved in research, just passion and curiosity. He talked through the work he did on iSTAT, diamorphine and his drive to improve the care of patients. It’s noticeable that he has a real focus on clinical care, and it’s that perspective and experience of an active emergency physician that is so important in our speciality. Big shout-outs to the team, the clinicians, the research nurses, and clear experience in the practicalities of real-world research. You can read more about Jason’s work here.
The Rod Little award session brought together the best of UK trainee research in the annual competition of 10 minute presentations followed by some rather tough questioning from the audience(!). I do like this session as it showcases the future of EM research and demonstrates the future of emergency medicine research. It was great to see some representation from so many current and past Virchester docs. We are delighted to share that Anisa Jafar won the prize with her work on Major Incident Management. She has previously worked with us in Virchester and we can tell you that she is not only a fabulous researcher but also an excellent clinician.
Izzy FitzGerald won the undergraduate prize on her work based on the REVERT trial. It was fantastic to see an undergrad take the stage at a major conference with such poise and professionalism and also with a clear message based around a patient narrative (which as we know Simon spoke on later in the day). She helped to create and evaluate a really cool device to reproduce the manometer used in the original trial, to great effect.
Rick Body, who seems to be everywhere at the moment, explained how RCEM grants pump-prime emergency medicine research in the UK, describing the process for funding a study comparing the HEART score vs the TMACS score. It’s a great example of how RCEM is supporting researchers and how the model of grants can really advance UK emergency medicine. Although these were preliminary results (largely because the study has grown and grown into a multinational 19 centre study!!!), Rick presented some headline data from two centres that use the same analysis. The bottom line is that both scores perform very well. TMACS appears to have a better performance than HEART (0.93 vs 0.85 on the ROC curves). In terms of assigning to risk groups then TMACS again appears to differentiate the very low risk and very high-risk patients better. Sensitivities are better with TMACS as was NPV. This preliminary analysis appears to show that TMACS is superior to HEART, but we await the full results from all 19 centres. You can read more about troponin from Rick and the team here.
It was a delight to see Will Townend be honoured with the David Williams’ lecture, speaking on the pursuit of mastery. He described the challenges of delivering high quality emergency care under really challenging circumstances in Hull. It’s a deprived area of the country in a health economy that has been under scrutiny for various reasons over the last decade or so. Those difficulties motivated him to get involved in medical education, first as head of school and now as lead for the development of the new EM curriculum that will launch very soon. It’s no surprise that we totally agree with Will that education and training are inextricably linked to service and the development of the future workforce and the sustainability of emergency medicine in the UK.
Over the next couple of years we’ll see the UK EM curriculum rewritten based not only on new criteria from the GMC but also huge changes to our specialty necessitating a rethink of our assessment process. A good curriculum is the foundation to build brilliant EM trainees, however as Simon rightly has championed, trainers still need to ensure they keep their own knowledge and skills up to date as no-one should be assessed by someone who really can’t do the job that’s being assessed. There was a lot more in Will’s talk, but for us it’s really heartening to hear that RCEM is working hard to improve the training experience and to deliver better assessment processes.
Our own Simon Carley as usual gave a fantastic talk, this time on story telling and narrative in emergency medicine. I’m not going to say much on this as he has a blog post that you should check out here, but as if by magic, the very next talk I saw started with a story. Chris Turner turned a brilliant story about a paediatric registrar, under stress from a difficult cannulation of a sick child, shouting at nurses who were unsure how to carry out his requests, into a gripping talk on incivility and how it affects you and everyone around you. Even colleagues who just observe rudeness experience a decrease in their productivity, an increase in errors, and an unwillingness to help others. There was a great question from the audience asking how, after an episode where he has been less than civil to a colleague, he is able to come back to work the next day and carry on? The answer was to fix things before you go home, and apologise to your colleague in front of your team – this clarifies that you were wrong, and also demonstrates to your team that the behaviour was unacceptable and not something they themselves should repeat. A fab message as I’m sure there are times where we all say or do something that we regret.
Today was a busy one with lots to talk about and lots to learn. We certainly had a good time! Only one more day to go, we hope you’ll join us for day 4 at EuSEM. See you there!
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