It’s the final day here at the Royal College of Emergency Medicine Annual Scientific Conference 2023 in Glasgow, and the St Emlyn’s team are poised with fingers ready to tap out the key messages.
Keynotes and RCEM Grant Updates
We started with a look at global health lessons that we can all take on. Ffion Davies who currently holds the presidency of IFEM talked about how the global picture of EM looks. There was a lot in this talk, but what was really interesting is that we are at the point of the World Health Organisation requiring emergency care as a core part of healthcare (amazing that it has not already, but it’s been quite the journey). We should also see an Utstein template for EM soon, which may not have a massive effect in the UK, but internationally it could really be a game changer. She described a lot of collaborative work between IFEM and RCEM, including research grants for young researchers (more on that from Stevan later). The bottom line from me is that IFEM is a really interesting organisation to work with and there are lots of opportunities to do so. Learn more here.
What can you do now?
- Pay it forward scheme online course donation (if taking an IFEM course)
- Support a delegate scheme, and we advocate the Supadel scheme
- Ensure open access or very low cost access to online courses (less than $10) for those in LMICs
Stevan Bruijns, who has many hats, but most importantly as one of our own St Emlyn’s team, talked passionately and with great wisdom about his journey through emergency medicine. He highlighted just how much of an outlier we are in the UK in terms of access to health and emergency care. Clearly emergency care is not going well in the UK at the moment, but if we take a global view then we are much better off than the vast majority of the world: A sobering thought. What I often take away from Stevan’s talks is his incredible ability to reflect on his journey and the experiences of those around him. His early life in South Africa was during apartheid, and as a child he was not aware of the issues around apartheid, but that these became apparent to him as he grew and became more aware of his privileged background.
You can read more from Stevan related to this talk here in an updated post from 2018.
He moved on to talk about the inequity of publishing, something that he has huge experience about as the recent past editor in chief of the African Journal of Emergency Medicine. There is clear evidence of bias in publishing and it’s not related to the burden of emergency care across the globe. Just one EM journal in the whole of Africa and none in South America!
Access to research is also a major problem, most journals do not allow access to papers unless people pay, and with the economic differentials it’s just too expensive (way too expensive) and so LMIC researchers use things like SciHUB which is illegal and not really a sustainable model, and certainly not a supportive approach from publishing companies who make billions of dollars annually. More on SciHUB here.
Stevan’s final thought, and I think Ffion would agree, is that the world is one family and we can all play a part. Another strong theme from both in this talk and in others I have heard is that it is absolutely essential to support local emergency physicians to develop themselves and their own systems that fit their local/regional/national needs. Global health is about supporting our global community, not about telling them what to do.
More from Stevan at St Emlyn’s here.
RCEM Grants updates
Next up we had talks from recipients of RCEM Grants for research, it was great to hear what they have all been up to.
Mohammed Elwan has looked into passive leg raise (PLR) as a means of determining fluid responsiveness in the ED. PLR seems to correlate with fluid bolus (in patients planned to receive one) when looking at change in stroke volume using thoracic impedance, which may mean we can use this to tailor fluid therapies to patients better than using other markers such as heart rate and blood pressure. Further trials may be incoming.
Sarah Wilson presented her work on the experiences of young people in the emergency department attending with self-harm or suspected fractures. Her key findings were that on the whole, young people were engaged with research and keen to be involved – they want their voice to be heard, so don’t be afraid to take on projects involving this group of people. They were also satisfied with their experiences, despite prolonged lengths of stay particularly in the self-harm group.
Sarah Midgley then told us about developing a tool to help to triage older adults with falls in the emergency department – this group often trigger on triage tools leading to trauma team activation, but frequently have co-existing acute medical problems that complicate this triage assessment. Her team used a Delphi model however experienced clinicians taking part used a lot of factors when trying to assess patients, and so with the number of statements felt to be important for immediate assessment, it was not possible to work those into a useable triage tool. There is a second part to this study which is ongoing so stay tuned.
Thomas Shanahan wanted to find out more about the experiences of emergency medicine academic clinical fellows in the UK. This was a qualitative study and thematic analysis. They focused on those in year two of their fellowship and it was great to read some of the quotes of how these fellows have benefitted from their experience, not just with new research skills, but time management, teamwork, and further opportunities on the road to independent thinking.
Nick Tilbury presented an RCEM qualitative before and after study on attitudes towards body camera implementation in the emergency department. Interestingly, more patients than staff thought it would be a good idea (96.5% of patients), however there was poor engagement with focus groups despite good response to surveys.
Liza Keating found that adults were less likely to get prompt pain relief for hip fractures than children were for long bone fractures and wanted to work out why. From RCEM audit data returns there also was poor consistency across multiple years even in the same departments. We are pretty poor at giving pain relief, and there is more work that every department can do to try to improve this.
Finally in this session, Cellan Liiv presented his undergraduate QI project on improving cardiac arrest care through simulation of the shocked patient post-ROSC. He was able to show that sim sessions can really lead to changes in knowledge and behaviour around resus. A really great project.
Late lunch today so after a quick break we were back for more
Simon was over in the EMTA session, which was led by the EMTA team and proposed using GIRFT processes to improve training. If you’re not familiar, GIRFT is getting it right first time and basically collects data into one portal and looks for variation in practice/experience. Where it is unwarranted variation they can advocate for change. So there are really important corollaries for training, where we also see unwarranted variation. Chris Moulton who leads GIRFT pointed out that there is a good correlation between good patient experience, good staff experience and good trainee experience.
It started with a round robin of speakers, largely summarising what good training looks like. A lot of that is in this document which is well worth a read.
It was interesting to look at the Q&A on the conference app for this session. Lots of questions that reflect significant frustrations and anxieties about training variation, AHPs and retention/recruitment. Too much for the panel to answer today, but I hope that EMTA will have time to review them and consider how we can move the conversations forward.
International RCEM Grant Updates
Meanwhile, Chris was listening to the International Grant Updates stream
We heard first from Anisa Jafar, who introduced the session and talked about the work the RCEM Global Emergency Medicine Committee has been doing over the last few years, including funding work around burnout, simulation, length of stay, trauma pathways, cardiac arrest, triage, community first aid programme, and paediatric malnutrition in low- and middle-income countries.
The future holds increasing funding to help to cover the admin costs of all this work to enable more funding to get to where it needs to get to. The committee have also created bursaries for 2 LMIC doctors to attend RCEM conferences alongside a four week clinical observership, which is truly exciting. There are more opportunities in the field so please have a look at the GEM Committee page here to gain a bit more understanding of all that is going on. More also from Anisa here at St Emlyn’s.
We then heard from some of the recipients of international grants on what they’ve been up to.
First was Gabin Mbanjumucyo who presented the results of the Rwanda trauma care study. This was a survey of patients thoughts and experiences around the care they had received, and using data to develop trauma pathways within the country. Gabin learnt that although trauma pathways have been shown to reduce mortality, it’s important to tailor these to the structures of healthcare that already exist in the country.
Kaushila Thilakasiri spoke on the development of the Sri Lankan Cardiac Arrest Study which aimed to create a cardiac arrest dataset and strategy. A theme of many of the talks over the last few days has been how Covid has impacted research and Kaushila’s talk was no different as the whole project was put on hold. The results from the datasets they have collected are currently pending publication, however there were some great lessons learnt from difficulties faced during the project, just as working in an unpredictable political and environmental state and dealing with a lack of national level research support, things we largely don’t think about too much in the UK.
Then we heard from Ankur Verma in a virtual presentation on his work improving paediatric trauma training using tele-simulation, aiming to establish if this is a feasible and effective way to improve knowledge and confidence. They took patient stories and turned them into scripts before recording videos. Pilot sessions allowed them to test and feedback on the simulations. Overall feedback was good and learners thought the sessions were effective, meaning Ankur and team will refine the simulations and upscale this for wider participation before re-evaluating it in the future.
Lunch next and then it was time for our final session of the conference
TERN and PHOTON
First up, Tom Roberts on the SHED study, a topic close to my heart having blogged about subarachnoid haemorrhage (it was my first non-conference blog for St Emlyn’s!) and published a BestBET on the topic as well. It’s a big area of interest for me and it was great to see Tom report the results of SHED, looking at CT to rule out SAH.
In their study, sensitivity of CT within 6 hours was 97% (92.5%-99.2%) and specificity 100% however the study was underpowered. If we look at a post-test probability though, a negative CT takes our pre-test probability of 13% and brings it down to less than 1%. At the 6-12 hour, 12-18 hour, and 18-24 hour marks the sensitivity drops a bit more however our post-test probability remains under 1% (though creeps up to 3% if you use the lower end of the confidence intervals at 18-24 hours).
But, given this New Zealand study reported a 99% sensitivity for CT to detect subarachnoid haemorrhage over a 10 year period, why are these results from the UK so different?
Well, looking at the false positives, only 1 patient with aneurysmal subarachnoid was missed within 48 hours of headache, and they had a strong family history of aneurysmal SAH such that the attending clinician requested a CT angio alongside the plain CT. That wasn’t your typical patient. The sensitivity for detecting aneurysmal subarachnoid haemorrhage within 24 hours therefore becomes 99.7% (or 1 missed patient in over 2000).
So, there is clear evidence for early scans, both for diagnosis and management so get them done early in this population. We need to separate aSAH and non-aSAH. We also need to talk to our patients about the scan results to help them make informed decisions about the path any further management or investigations might take.
Fraser Birse presented the ACS-ED study, which aimed to look at how suspected cardiac chest pain is managed in EDs throughout the UK and abroad. It was interesting to hear that there is so much variation in how we manage these patients. This variation not only includes which troponin type is used (it’s 50/50 between I and T!) but also timings for initial and repeat troponins, and discharge and assessment pathways. There is also big variability in which risk scoring systems are used and what levels of troponins are used to make decisions.
Despite all of this, there is very little variation on length of stay, so it doesn’t appear that any one particular approach helps to move patients forward more quickly. Do we therefore just all need to adopt a nationalised approach?
Finally, TETRiS – trauma emergency thoracotomy for resuscitation in shock. Lisa Ramage and Harriet Tucker talked about resuscitative thoracotomy and highlighted the various protocols and variations between these. We often think of blunt vs penetrating when the real issue is around the mechanism of the arrest. TETRiS aimed to provide the first national prospective evaluation of RT practice, looking at the whole patient pathways to better understand timelines, interventions, and outcomes, and improve the evidence base for the procedure moving forward.
So, what did they find?
116 thoracotomies performed over 12 months, 70% were pre-hospital, 70% were for penetrating trauma. The median age of patients was 30, and 83% were male. A third of the prehospitally performed RTs were conveyed, the rest were declared dead at scene. 62% of RTs were performed for suspected tamponade and 26% for management of intrathoracic bleeding. 16% of cases had POCUS – a third of those showed tamponade.
In terms of outcomes, 43% got ROSC, however the 30 day survival was only 7% – of these survivors, 3 were prehospital RTs, 5 ED thoracotomies, and all had a variety of injuries. Neurological outcome data are still being collected.
This study shows that this is a rare procedure – occurring twice a week throughout the UK prehospital and ED services which has implications for training and competency maintenance. Ongoing national evaluation and audit are still required moving forward to gain the best dataset we can but this study has produced some questions around whether we can select out which patients will benefit, maybe through use of ultrasound? We look forward to reading the full paper when it is published and reviewing it here at St Emlyn’s.
Well, there we go, that was the RCEM Annual Scientific Conference 2023. A huge amount of learning and three days of brilliant presentations on the current world of research in emergency medicine and beyond. We’ve had a fantastic time, we hope you have too, whether there in person, online, or following along with our blogs.
The next RCEM conference will take place at the ICC Wales just outside of Newport on 16-18 April 2024. We hope to see you there.