— Brian Burns (@HawkmoonHEMS) March 23, 2018
Day two formally kicked off with a series of workshops. Based around the camp these took on a relaxed and interactive style. We all slept well in the glamping field and began with a fabulous (and very large) breakfast.
Led by Natalie, with Sandra, Ross, and Ian got together to run the feedback workshop. This is based on the half day session we run on the TeachingCoOp courses and it’s one of our favourite sessions. You can read more about the principles here on the blog post we set up specifically for the day at #badEMFest18.
There were also workshops on vehicle extrication and on TB/HIV management in South Africa.
MedEd workshop was weirdly emotional for me today.
Went from “I’ve never received feedback” to “Maybe they just did not call it feedback” to “Maybe I just didn’t get the kind of feedback I wanted,”
And, finally, “I’m going to start asking for feedback.” #badEMfest18
— Barefoot Megz (@Doc_Megz) March 23, 2018
— Geoffrey Menzies (@geoffmenzies) March 24, 2018
Can I X-ray this pregnant patient with Penny Wilson.
The simple answer is yes, but with caveats. In general, if you need to do an X-ray or CT in a pregnant lady then you do need to do it and you should just get on with it. However, you might want to stop and think a little before you do…..
- Do we really need a scan or are we just doing this because of protocol?
- Is there an alternative imaging modality. Think about ultrasound or MRI as alternative modalities. This might be something that you should discuss with your radiological buddies.
- Reduce the dose. Again this is something that you need to talk to your radiological chums about. There are new scans, alternative protocols and modifications than can reduce the radiological dose to the foetus. For example you might not do a full triple phase abdo scan.
Penny asked us all to be the mutant ninja turtles of emergency medicine by being totally rad. Fair point that reminds us that we should tailor our management to the patient. You can read more of Penny’s thoughts here on her excellent blog.
Can I XR this pregnant patient, @nomadicgp asks? Yes – but:
1. Is it necessary?
2. Is there an imaging alternative?
3. Can we reduce the dose?
Discuss with radiology colleague and with the patient – treating mum’s best interest is best for baby #bademfest18
— Natalie May (@_NMay) March 23, 2018
Foreskin problems in children.
Ross has spoken and blogged about this before on the St Emlyn’s site and he gave a great presentation about the 5 most common foreskin problems we see in the ED. Apart from the rare condition of xeroderma obliterans foreskins just don’t need treating. You might think you’re doing good work by sticking things down the end of a willy or standing over a small child asking them to pee, or even more bizarrely asking someone to stretch their kid’s foreskin but you’re not. On that last point Ross reminds us that you should not stretch anyone’s foreskin unless specifically asked to do so by the owner of the foreskin. Think about that for a second before advising it.
Ross also gave a really interesting presentation approach. He placed notes in the audience and then got delegates to ask questions as if they were parents asking about foreskin problems in their own sons. This was both funny and interactive. I’ve not seen this method of audience involvement done before, but it worked and I shall be adopting it myself in future.
Tracheostomy emergencies in children.
This was a great presentation on the management of children with technology limited conditions (e.g. tracheostomy). In the past this meant that children with certain conditions could never get home because they had a condition that was perceived to be unmanageable in the community. In particular the issue of managing tracheostomies meant that many children were living their entire lives in hospital or care home settings. This is a real challenge in South Africa where many familes live in really challenging environments. Jane Booth explained how she and her team worked to create a program that permitted families to take their children home.
This is an amazing example of how clinicians need to work with families to help patients. We cannot do this from a purely medical model. If you want to know more follow this great link. www.breatheasyprogramme.org
The challenge of Ophthalmology in remote South Africa.
I have a vested interested in eyes owing to Prof Fiona being one (I am super proud of her so no apologies for mentioning her here). Anyway, it’s rather different in South Africa as compared to a major teaching centre in the UK. The scope of practice is wider and there is a lot of emergency work that needs sorting. William Mapham introduced us to his work and also showed us how to make a nifty eye irrigation device out of a butterfly needle set. This was awesome and only led to 35 needlestick injuries in the audience. William is clearly a fantastic chap who was just incredibly friendly and nice. He spent a lot of time talking to delegates about eyes and tips and tricks throughout the conference.
The other incredible innovation he talked about was the use of the VULA app to advise and manage ophthalmology problems across Africa. This was incredible use of technology to support eye care and you should visit the site to learn more. It’s incredible work that’s making a real difference to patients and staff.
As for the hair style…….
— Ian Summers (@IanMeducator) March 23, 2018
Chest drainage and Autotransfusion with Tim Hardcastle
Tim is a trauma surgeon working in South Africa. He’s widely regarded as a top chap who has placed over 2000 chest drains (many more than me) in his career. Back in 1997 he started as a medical officer in Tygerberg trauma unit. Like many South African EDs they had a chest drain holding area like the one we discussed in Mitchell’s plain. The average stay for a haemothorax was 72 hours. The population was mostly gang related (including the Junky Funky kids). Treatment involved exercising and mobilisation.
- Put Saline in the chest drain bottles as that means that red cells don’t lyse. If you put saline in the bottle you can then retransfuse the mixture back into the patient (UK docs are passing out at this point).
- They moved from bottles to an XPand drain and the SINAPI drains. This shortened the tubing length from patient to bottle.
- The latest versions are much more complicated and now involve a port to allow the drainage of fluid into a blood giving set for
- Put the retransfused blood back through a blood warmer as you still need to keep it to body temperature.
- You still need to manage coagulopathy by replacing plasma (as these will have been consumed before you auto transfuse).
- You may add a small amount of heparin to the drainage bag (though you may not need to if you doi it quickly).
- For the chest it’s a fairly easy task. For abdominal blood you do need specialised machines to wash and restore the red cells to a point suitable for transfusion.
It’s really started me thinking why this is something that we don’t do in the UK. The patient’s own blood might be better than giving O-negative blood (which has not been fully cross matched). Is anyone in the UK using autotransfusion in the ED? I suspect so but I don’t know.
Debate on trauma coagulopathy.
This debate focused on the management of a hypothetical patient, a cyclist with exsanguinating haemorrhage from a groin injury. It was a debate about how we manage from scene to definitive care.
- Prehospital before anyone arrives. Direct pressure to the groin by hand. Indirect to the aorta or direct pressure using the knee to the groin.
- Prehospital team with paramedics arrive. Haemostatic dressings are available and that would be used, but a reality check here. Paramedics in SA only have one of these haemostatic dressings per year (half in jest) and so there is a real resource debate about which patients get it. There is also the problem of having to remove the current haemostasis to get to the wound. Having said that there is a preference to give localised pressure rather than wide pressure. Two fingers in the right place is better than a knee anywhere. Whatever, bleeding control is most important.
- Once some bleeding control is in place an IV for analgesia and some TXA is appropriate (but no fluids if he is still awake). We also talked about the idea of using a Foley catheter into the wound, blowing it up and tying it off. You can read more about this on the Resus.me site from Cliff Reid. I have done this in Virchester and it really worked.
- Beyond the scene and on transport to hospital then things might get worse. If the patient loses consciousness then it’s tough as there are real problems in managing the priorities of airway, breathing and circulation. The decision to intubate is a challenge. REBOA is a possibility in some centres, thoracotomy and direct aortic compression is also an option but these are rarely available and last chance techniques. Clearly you also need to be able to take that patient to a place where they are capable of receiving the patient and carrying on that level of resuscitation. As David Stanton spoke about yesterday that’s not the case in many health economies.
This debate highlighted the importance of bystander care and also reinforced the theme that care, opportunity and outcome are context dependent.
#BadEMfest18 allowed me to be vulnerable and safe with colleagues for the first time.
I learned a lot of hardcore stuff too, but this was the experience that most affected me.
I feel connected, like I belong; and INSPIRED.
“Thank you” could never describe my feelings.
— Barefoot Megz (@Doc_Megz) March 25, 2018
Intubation of the profoundly shocked patient. Farzana Araie.
This is a worry for all of us in the ED. The patient is extremely vulnerable at the process of intubation. Farzana talks about the Propofol/Sux approach (unmodified) that ended in the death of patients. She is an incredibly experienced trauma anaesthetist and she worried about Propofol/Sux in these patients unless you are really experienced in giving those drugs IN THIS GROUP of patients.
Here’s the top tips for approaching the profoundly unwell patient aroundthe concept of the physiologically challenging airway. The patient who needs a tube now, even though they are only partially resuscitated must be carefully nurtured through the RSI. Think about how you can achieve the following.
- Balanced technique
- Haemodynamically neutral
- Monitor like a pro
She mentioned a shock index (HR/SBP) of more than 0.8 as being highly predictive of cardiac arrest post intubation (about 4%). So in that group you either need to resuscitate before you intubate (best option) or be really scared and really, really careful.
In terms of drugs then the choice is those that reduce the sudden change in physiology that takes place at induction. Propofol is not your best choice, it really isn’t and despite the enthusiasm for some UK anaesthetists that it’s OK in their hands it probably isn’t as good as they think.
- Ketamine is the best agent we have for induction. At about 0.25-0.5mg/Kg (which is lower than we use in Virchester)
- Use high doses of Roc. Farzana suggests 1.6mg/Kg (which is more than we do in Virchester). Speaking to colleagues from Sydney HEMS it was interesting to hear that they agree that 1mg/Kg Roc is not enough (they are up to 1.5mg/Kg in this group of patients).
- Get push dose pressors ready. You will probably need them. Ephedrine, adrenaline or phenylephrine should be drawn up and available.
Interestingly the use of opiates as part of the sequence was not advocated whereas we use fentanyl as part of the RSI process.
Understanding gangs and violence in Cape Town.
It’s always good to hear from non-medical experts at conferences. Especially when it links to our practice. Don Pinnock is a criminologist who gave a talk that as a visitor was simultaneously terrifying and fascinating.
In just one year the Western Cape police reported 52895 serious assaults. The murder rate is 6/day in Cape Town. 12000 robberies a year and most of those involved are young (average age 25). There are also problems with underage sex, domestic violence, malnutrition and poverty. Cape Town is one of the most dangerous cities in the world (more dangerous than Johannesburg), but that violence is focused in the poorer areas of the city.
The murder rate is high, but only 7% is gang related. 42.9% are rape related. So it’s not just about the gangs, it’s about the home and the domestic situation of many Cape Town residents. The terrifying levels of sexual violence and subsequent murder were difficult to hear and comprehend.
There is a gang problem, but it’s also a youth problem. The stats are horrifying and the lived experience of all those who are touched by this must be awful.
Don Pinnock talking about how the violence epidemic in SA starts at birth. Biosocial stress in preg&FAS > educational drop off > massive inequality = violence/drugs/gangs. Need to understand social determinants to ⬇ horrific violence stats & not just in SA.#badEMfest18
— Angharad Spencer-Matewere (@AngSpencerM) March 23, 2018
Drugs are also out there and the effect on society starts before birth as children are exposed to violence and drugs even before they are born. Many mothers are under nourished and exposed to drugs and alcohol with high rates of foetal alcohol syndrome. These can all lead to changes in behaviour later in life. This is really a whole society problem that ultimately manifests in increasing violence and crime in the Western Cape. Similarly the experience of early life leads to eventual life outcomes. Longitudinal outcomes for kids exposed to serious stress in the first 1000 days of life are horrendous (see Dunedin project).
Gangs often offer a solution to the personal and family problems that many South Africans face. In many ways gangs provides a familial type structure that is needed to support people in difficult conditions. The problems of absent fathers and poor fatherhood in general is also a real driver towards gang formation and persistence.
Ambulance services in South Africa.
Pumzile Papa gave a great talk on the experience of being a paramedic in South Afica. These are brave people who face regular danger in their working practice. How that all fits into a private/public system is complex and not always in the best interests of the patient or the community. There are people out there like Pumzile who are working hard to improve care, but this talk really showed the barriers and hurdles that lie ahead.
— Ian Summers (@IanMeducator) March 23, 2018
Saa’d on superbosses.
Saa’d is an amazing human being, working in Khayelitsha hospital as an emergency physician and of course as a faculty member on the teaching course we ran earlier this week. He talked about his early experience of not getting supported as a junior doctor. He prayed and asked for guidance on how he could develop into a leader of an incredibly busy emergency department.
- Superbosses amplify the talents and efforts of their people. That’s tough in some parts of South African medicine (and let’s face it pretty much everywhere in the world wnen you talk about emergency care – NHS included).
- Superbosses shield and protect their juniors from the harms that can pervade our practice. Be that clinical or moral they must support their juniors and coleagues.
- Superbosses tell their staff that theyare making a meaningful difference to the department and to their patients.
- Superbosses help promote and promulgate the ideas of their staff.
- Superbosses recognise and reward effort.
- Superbosses role model positive behaviours and recognise and reward them in others. This is especially important in stressful events.
- Superbosses create a positive environment where everyone feels valued.
If that’s unclear then I can give you Saa’d’s number as he is truly a superboss.
Inspiring talk by @slahri7 about superbosses.They shield you, value resourcefulness>resources, team KNOW work is meaningful, amplify skills, know their ppl&create workplace that is more than the sum of its ppl. Can see why there's such draw to work in khayelitsha!#badEMfest18
— Angharad Spencer-Matewere (@AngSpencerM) March 23, 2018
Sweet dreams are made of these. Natalie May
Nat talked to us about the importance of rest and sleep. You can read more about how we value sleep in Virchester here. The take away messages for me were.
- Beds are for sleep and sex. Avoid doing other stuff in them!
- Have a routine about how you get to sleep and how you manage your time around shift work.
- There are evidence based approaches to sleep and shifts. Use them.
- Don’t take electronic devices to bed unless you need them for point 1 :-0 . In particular do not take screens to bed. The light on your phone will try and keep you awake. Don’t let it.
- Alcohol is not your friend when it comes to getting a great night’s sleep.
Human/Kind with Andy Tagg
Andy talked about how we cope with seeing suffering and harm in the environments we work in. Children are kind, all of them really, it seems like a human trait, but somewhere between childhood and adulthood it seems to fade
Being kind increases your empathy and exgtends your life. It makes life more meaningful.
There is a difference between kind and nice. Nice is a societal construct designed to give power to people. Andy wants us to be kind, but how? The most important thing is that we can be kind and it does not take that much. You can be kind in a single moment with a single person.
Great talk by @andrewjtagg bout taking empathy back to look, listen, think.Embracing silence, active listening, connecting w pts and our shared humanity NOT just w 'easy' patients but those which really challenge us too. It's what we'd want for relatives.#badEMfest18#dftbkind
— Angharad Spencer-Matewere (@AngSpencerM) March 23, 2018
In medicine we are not always kind, but it could be. When we meet patients we should avoid judging them and really listen and understand what they are saying to us. In some ways this was a call back to the basics of patient/clinician interaction. Perhaps that tells us of the concern that medical practice changes us. It’s a really tough job and there is no doubt that it changes us. Andy challenges us to stop and think about how we deal with patients who we meet and especially those who are different from us or who are difficult for us. Challenges abound in our world, but by making a connection as a human being is a way for us to rekindle the kind human in all of us.
— Andrew Tagg (@andrewjtagg) March 23, 2018
Andy ended with an exercise in kindness. Scattered around the room were a number of envelopes that contained cards of thanks for distribution to whoever the envelope opener thought deserving. Also there was money in each card, this was to be used for an act of kindness. What an amazing idea and a great way to express Andy’s values and the values of this conference. If you follow the #badEMFest18 time line then you will see several examples of what happened next (it was all good).
You can read more about Andy’s talk here on the Don’t Forget the Bubbles website.
The #BadEMFest18 experience has simultaneously renewed my faith in Emergency Medicine, & reassured me that I'm doing the right thing for myself right now by quitting training. It was inspiring meeting people who've been brave, done things differently & found their own path.
— Jennifer (@coffeeheadaches) March 25, 2018
Thoughts at the end of Day 2.
Another great day in Greyton. The evening ended with some fabulous music from Jono Simons Trio and Paige Mac around the camp fires. We also tasted some 6-dogs Blue gin which was amazing. I’ve brought a bottle back to the UK and it’s SO good I need to find somewhere that imports it here.
It was a truly magical day.
— Andrew Tagg (@andrewjtagg) March 29, 2018
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