There were great excitement at the Aviator airport hotel this morning as our sponsored delegates(dubbed the Supadels) prepared for transfer to the conference venue. Over the last few months delegates registering for #EMSSA2017, as well as persons with a deep connection to African Ubuntu donated to this fantastic cause.
This year 68 persons donated ZAR 147,000 ($11,000) to sponsor the attendance of 17 delegates from a number of African countries (including Nigeria, Ghana, Tanzania, Ethiopia, DR Congo, Rwanda and Uganda). These delegates would not have been able to fund their attendance without Supadel. A special thanks has to go out to the #DasSMACC delegates who contributed three quarters of this year’s sponsorship. This is the eighth year that Supadel has enabled peer-to-peer sponsorship through the power of #ubuntu. Over the last eight years Supadel channelled a whopping ZAR 1.9 million ($140,000) of sponsorship to 206 delegates from a total of 598 peers. You can also become a Supadel superhero by clicking here and donating.
Part 1: Emergency care on the cutting edge Next level resus: The periarrest tox patient – Zeyn Mohammed
Zeyn took us through a range of challenging cases for the critically ill tox patient. Whilst it’s worth re-iterating that a lot of tox management is simply about supportive management, there a number of situations where specific therapies are recommended.
A good reminder of
High Dose Insulin, Euglycaemic Therapy(HIET): Monitor glucose very often. Remember to also check the potassium levels.
Use of ECMO in the management of the peri-arrest tox patient. ECMO should ideally be initiated within 4 hours.
Lipid resuscitation therapy can be considered in lipophilic cardiotoxic drugs like Amlodipine, Verapamil, Amitriptyline, Atenolol, Propranolol.
The critical care transport of patients on & for ECMO – Maryna Venter
This built on Maryna’s talk yesterday. Within South Africa, most patients are actually referred for ECMO rather than on ECMO. That means that while transporting a patient ON ECMO is logistically difficult, transporting a patient FOR ECMO is clinically challenging.
The patient for ECMO is referred when all other conventional interventions have failed. These patients are already physiologically strained and have very limited physiological reserve. The transport stress may push these patients over the edge. Monitoring appropriately and optimise before transport. Anticipate instability.
The patient on ECMO should have coordinated movement and deliberate securing of equipment and indwelling devices. Take extreme caution to avoid kinking of the ECMO lines or the anastamosed perfusion lines. You must be able to see all lines – if the patient remains exposed adjust the vehicle’s temperature.
In summary, ECMO retrieval should be done by a multi-disciplinary teams that are experts in their own field; they complete they’re individual role well.
Paediatric trauma – important considerations: Brittany Murray
Brittany is a paediatric emergency medicine specialist originally from Canada but has crossed the border down to the USA. She has been involved in a lot of fantastic work in Tanzania helping Muhimbili Hospital set up their EM programme and training the doctors there.
She gave a great review of paediatric trauma, with a lot of focus of ABCDE and doing the basics well. There were several pearls about important differences in assessments and injury patterns.
Children’s ribs are more springy, and their mediastinum are more mobile. This means that significant lung injury can be present without rib fractures, and haemopneumothoraces can be hard to detect on examination.
She asked why an adult tachycardic trauma patient is assumed to be bleeding until proven otherwise, but in a child it is often put down to pain or anxiety? She reiterated that signs of haemorrhagic shock can be very subtle until it’s too late.
She adds an F for FAST scan and Family, who can be easily forgotten in the organised chaos of resuscitation. A parent at the bedside may achieve more anxiolysis than any drug we have. We must also do what we can to reduce radiation exposure where possible.
Hypotension and volume: Intubation and ventilation has a significant physiological impact. If your patient is already on the edge of CVS collapse, you will precipitate it if you paralyse, intubate and ventilate them. Beware the patient with a shock index >0.8 as they have a high likelihood of post intubation collapse. Use USS to determine the patient’s intravascular status, look at the IVC, the heart and the lungs.
Acidosis: Again the severely acidotic patient may crash on you. Avoid bicarb(unless tox patient with specific need). Consider gently bagging the patient throughout RSI if hypercarbia a problem.
Hypoxaemia: Your patient will be apnoeic for some time during intubation. Ensure you’ve got some physiological reserve. Avoid bicarb(unless tox patient with specific need). Work hard to maximise preoxygenation. Head up, PEEP, ApOx techniques all advocated.
Metabolic: Correct hypoglycaemia and of course hyper/hypokalaemia if you can.
Dysrhythmias: Again related to metabolic and biochemical abnormalities. Be very careful about hyperkalaemia(especially with Sux).
Drugs: Go for ketamine as an induction agent, consider decreasing the dose. Use Sux or Roc, but ensure that you use higher doses than in normal anaesthetic practice. 2mg/Kg Sux or 1.2mgKg Roc.
A quick summary would be watch out for the sick, the old and the dehydrated.
Through the looking glass: Prehospital ultrasound– Dave Stanton
Dave is the first paramedic in SA to be level 1 accredited in ultrasound. In a country with potentially long transport times USS can be used to get an early diagnosis to direct the patient to an appropriate facility.
There are also direct considerations too as the rate of penetrating trauma(and trauma in general) is much higher here. Dave gave examples of using USS to identify patients with pericardial effusions and to then direct them to facilities with CT surgery on site.
We also now know that ECHO is increasingly helpful, if not essential in cardiac arrest management. If we want our paramedics to deliver the best ALS they can at scene, then surely we need to give them the tools to do so.
Dave put together a quick demo of how it might be used by paramedics. A few caveats on that USS can be relatively easy to deliver in a lecture environment, it’s tougher at the roadside or in a moving vehicle. However, with proper training and oversight Prehospital USS by paramedics in SA appears to be possible and potentially very useful. Prehospital USS should be implemented in the context of a system of care.
REBOA in SA: Breaking the ice– Vicky Jennings
Vicky is a trauma surgeon in Johannesburg and describes the development of REBOA through the ages– lately, the literature has exploded. This may be considered in the prehospital environment. It should be utilized in the correct patients for the correct indications.
Zone I: Aorta above the celiac artery. Measure the catheter to above the xiphisternum
Zone II: No go zone, between celiac artery and renal artery.
Zone III: Below the renal arteries. Measure the catheter to the umbilicus.
Vicky speaks of partial occlusion with REBOA that can be titrated to the blood pressure.
Local complications include embolisation, amputation, pseudo aneurysm.
Vicky stresses that REBOA is a bridge to definitive care– it buys you time. That extra time can be used to continue resuscitation or to give you a window to get through the CT scanner to further define pathology prior to theatre.
In the context of trauma, it is essential to keep working on/stabalising the patient until you can hear someone say:“Scalpel, please.” Optimise the patient for theatre and a good outcome.
Keynote: United in Emergency Care– Gabin Mbanjumucyo
Gabin Mbanjumucyo is a senior Emergency Medicine resident in Rwanda at the University of Rwanda and President of the Rwanda Emergency Care Association. He highlighted the importance of emergency medicine in reducing morbidity and mortality in time sensitive disease states. In Africa, there is great opportunity to improve outcomes, especially in malaria, HIV/Aids and perinatal diseases. He notes that populations projections for the year 2050 are estimating Africa to have an increased burden of disease, expanding population and increasing demand for Emergency Care and that it is crucial to prepare now for the future.
He wisely notes that Africa is not a homogenous population and neither are systems within African countries the same. One can not apply a South African policy to another African country as burden of disease, populations and resources are not the same. This discrepancy is most notable within Emergency Medical Services(EMS) in different countries; helicopter based retrieval may be present in one whereas donkey-drawn carts may be the most used form of transport in another.
Focus on improving and strengthening EMS is crucial in African countries as patients must be timeously transported to hospital for further care. When introducing validated emergency systems processes into a new environment, such as triage, it is important to get buy-in from the hospital and its personnel so that the new system is embraced and incorporated. Traditions such the“first-come, first served” way of seeing patients needs to be patiently challenged and changed when developing an Emergency department.
The impact of emergency medicine training was emphasised by Gabin as he reported mortality outcome data from the first year following the introduction of EM at his hospital. There was a 5% overall mortality reduction compared to the year before. This remarkable achievement was accomplished when there were only 6 residents in EM at the time, being trained by passionate and dedicated American EM Physicians who assisted with developing and running the Emergency Medicine Residency Programme. He reiterated that even in low income countries like Rwanda, implementation of Emergency medicine residency programmes is doable.
Gabin reflected on how he was sponsored as a Supadel and how he got exposed to Emergency Medicine conferences during this training and how this impacted on his growth. He ended the talk by reminding us of the wise words of Nelson Mandela,“It always seems impossible until it’s done”. Gabin further stated that just as leaders are not born, they are grown, likewise systems are grown and built over time.
Keynote: Health, wealth & emergency medicine in the 21st century– Simon Carley
Simon Carley is professor of Emergency Medicine and consultant in emergency medicine at the Manchester Royal Infirmary as well as consultant in paediatric emergency medicine at the Royal Manchester Children’s Hospital. He highlighted the changing environment in which EM physicians are finding themselves world-wide, and Africa is following this trend.
Populations are ageing, and with increased longevity comes multiple co-mobidities and polypharmacy which leads to complexity in medical decision making. Advancing technology and increased expectation may make decision making more, not less difficult. Simon described that in LMICs decision making is made further uncertain due to the limited research done in our populations, which makes our decision making even more tenuous.
Complexity of disease, subtlety of disease presentation, more difficult decision making and multiple therapeutic possibilities are just some of what the future holds. Emergency Physicians will have to astutely apply pre-test probability in the context of their population, while managing risk safely. This requires Emergency Physicians to ensure that educating future clinicians is adapted to this complex environment. Despite the change that is already afoot, Simon challenged us to see the future as exciting and bright and to embrace our role as clinicians empowered to manage complex patients effectively.
Part 2: Emergency care on the edges
Taking HIV to Heart– Dr Pravani Moodley
Great speaker from Johannesburg speaking about cardiology considerations in HIV positive patients. Can significantly change our approach to the patient!
She spoke a lot about the below Heart of Soweto study which is worth a read.
Of note: 9.7% of de novo cases of heart disease were identified as HIV-positive. HIV-associated Cardiomyopathy making up a large portion of these. HIV cardiomyopathy is the leading cardiovascular disease in most LMIC, it is a Stage IV defining disease with multifactorial aetiology. Echo is gold standard, Rx CMO is the same as non-infected(other than ARVs)
Pulmonary Hypertension is present in 1/200 HIV positive patients(no association with CD4) compared to 1/20 000 in the HIV negative patients. Presenting feature is usually dyspnoea but this leads to diagnostic difficulty as dyspnoea is one of the most common presentations in HIV patients
Atrial fibrillation– Increased arrhythmogenic potential in HIV. Why? fatty infiltration, myocardial necrosis. Management still fairly similar with rate control & anticoagulation, however we don’t actually know if risk stratification scores such as CHA2DS2-VASc can be used in these young HIV patients.
From HAART TO HEART(Problems with Drugs): Abacavir increases platelet aggregation, zidovudine can result in focal fibrosis, protease inhibitors & ritonovir booster drugs can cause dyslipidaemia and insulin resistance. Overall message is that all these factors can lead to accelerated atherosclerosis so it is important to consider the increased risk of CAD in HIV patients. Drug interactions to note: Protease Inhibitors can increase serum simvastatin levels 300%: which can lead to rhabdomyolysis.
*Side note: Well documented that Framingham underestimates CAD risk in HIV.
Discussions with fellow clinicians after the talk all extremely interested.. Serious practice changing stuff that to us South Africans was of extreme importance in our day to day work!
Panel discussion: But what’s worth more than gold? A debate about knowledge translation
Chair: Annet Alenyo
Panel: Stevan Bruijns, Michael McCaul & Petra B
The panel wasted no time getting into the nitty gritty of knowledge translation. Michael argued that knowledge translation is about getting evidence into practice and policy; that it should be seen as te process of bridging the gap between what we know on the one hand, and what we do on the other.Petra explained that the terminology used around knowledge translation is often confusing. People use different terminology but often meaning the same thing and similar terminology but often meaning different things. Knowledge translation and utilisation are not the same thing. As a nurse educator and researcher, Petra has noticed that‘evidence based practice’ are considered buzz words to know amongst many, but few can explain what it actually entails. An audience member commented on using images images, videos, visual aids, and hands on teacing to break down the knowledge translation barriers.
Stevan emphasised that the gap between knowing and doing is a lot bigger in lower resourced settingsas addressing knowledge translation effectively is tied to resource availability. Ironically the majority of us are unaware really how big the gap is for much the same reason. For instance the management of ACS in emergency care is widely publicised in publication, lay press and social media(who has not heard of the HEART score?) yet the vast majority of the global population will not have access to a high sensitivity troponin if they presented to an emergency centre with chest pain. This highlights another conundrum as often acute care providers practising in low- or middle-income settings(which makes up 82% of the world’s population) are not aware that the resources they use do not fit the evidence. You can see where this is going. Sub Saharan Africa makes up about a billion of the world’s 7 billion strong population. It is highly represented in burden of disease, but not so much in availability of resources. In many parts you’ll be hard pressed to have an ECG done, let alone a troponin of any kind. How does knowledge even begin to translate under these challenging circumstances.
Stevan explained the difference between publication citations and views. Citations are when other researchers quote your work in their work; it represents a researcher’s perspective. Views are when folks read your work; it represents an audience’s perspective. Interestingly there are no correlation between citations and view. Highly cited publications often have relatively fewer views than less cited publications. Accessing research and doing research are likely on opposite ends of a knowledge economy spectrum of sorts. Less mature knowledge economies(like those found outside high-income countries) derive less new research than more mature ones. Quality metrics, such as impact factor, completely ignores publication views and in a stroke invalidates what little research is done in less mature knowledge economies.
Petra highlighted some key challenges in knowledge translation locally
Folks don’t know how to read research and as a result devalues its importance in their reference perspective.
“Research-phobia”– it is scary, and I don’t understand a lot of the big words
Then when folks DO get over the above twobarriers and read the research,they discover that they don’t have the resources to follow it through into practice and despondence sets in.
And yet where we manage to break through these barriers the pace of generating research picks up.
A large bias that exists in publication is should largely be in English. However, in order to reach three quarters(S of the world’s populationone needs to speak at least 40 languages. He pointed out that this conference is conducted in English, that the top three languages understood in Africa is English, French and Arabic(none African in origin). And yet Africa is one of the most linguistically diverse places on earth. Translating knowledge needs more than European based languages to reach into the numerous corners of the world! If you can turn words into pictures wherever possible it can help break through language barriers.
#FOAMed also has a High Income bias. Should we encourage African trainees to focus on local research and practice or is there a healthy balance?
If you’re a young researcher then there are opportunities here in Africa. Get in touch with colleagues who are already working hard to build an evidence base for Africa. We’d suggest stating with @codingbrown.
Snakebite management in low resource setting– Arno Naude
South African snake expert Arno Naude did a rapid fire pearls of wisdom talk with us.. he managed to cram hours of information into a fantastic talk!
Call an expert, send a photo. Eye witness descriptions unreliable. Never touch the snake even if looks dead. If you don’t know what snake: then look for clinical patterns.
Neurotoxic– lethargic, ptosis(cobra/mamba
Haemotoxic– its not an anti-coagulant, it is a coagulant. bleed because clotting factors used up.
As a rough overview there are two types of anti-venom used in South Africa.. The polyvalent anti-venom covers the“red list snakes” 1 x Rinkhal, 2 x Adders, 3 x Mambas, 4 x Cobras.
1 snake has its own antivenom: The Boomslang– this is an easier bite to diagnose due to bleeding at wound site & distant & takes slightly longer to cause severe effect, so there is time to transport to where the anti-venom is (or vice-versa). There are 2 snakes with no antivenom: the woods spitting cobra(expert has never heard of a bite) & the vine snake– if you get bitten by this snake you DESERVE it! it means you were messing with the snake(very rare bite).
Give antivenom slowly over 30mins as IV infusion. Always be ready for anaphylaxis with antivenom– extremely common. If happens, give adrenaline IMI. Initially just slow down the infusion, only stop if absolutely have to. IO admin of anti-venom, has been done before and worked. Dose of antivenom the same for adults and children. The snake did not give a paed dose of venom!
40% of all snake bites don’t inject venom(fangs damaged or duct blocked, snake cold, snake not angry enough!)
Any snakes have stripe from head to tail then nonvenomous.
If a snake has 2 rows of bites = non-venomous
Mole snakes: like to chew so leave bad wound, not venomous
Python: leaves big marks/tears(>200 teeth) but NOT venomous
Interesting facts:Fangs maybe the ones at back,. the big front teeth are just to hold the prey whilst injecting venom!
If you have no antivenom: intubate/ventilate in the meantime. If can’t get antivenom use blood products ot treat coagulopathies.
not uncommon for limbs/digitis to look like they need amputation of fingers/hands.. almost never do!
Minimal role for fasciotomy in snake bite.. big myth!! Even if looks like it clinically, check the compartment pressure. This has been proven with Stryker needles & pressure assessment!
If you do a fasciotomy they don’t heal well..
NEVER do a debridement in the first 4 days
Mozamambique spitting cobra compared to a gangster on Tik.. climbs into peoples beds, and then bites them!
Rinkhals sprays venom in eyes..
They like to play dead. Connect nasal prongs to water and run freely into eyes for 20mins.
Cape Cobra: can sometimes need up to 21 days vent. Patients are locked in and so they can hear you but they are completely paralysed.
Mambas are the worst: best device needed is an ambubag. they will all recover. Put BP cuff above systolic as a tourniquet.
Monitor the Urine output and do a dipstix.
In the rural setting: Do a 20min whole blood clotting test. put blood into container. wait 20mins. turn it over.. big clot: looking good. Runs like water=bad
Checkout the VAPP course on Venomous Animals and Poisonous Plants here.
No prophylactic antibiotics in snakebites. They don’t make a difference.
Observation period in asymptomatic : Unknown snake 12-24 hrs, Nonvenomous 6 hrs
Dose of antivenom the same for adults and children. The snake did not give a paed dose of venom! Give 8 amps irrespective of patient size
Always be ready for anaphylaxis with antivenom. Extremely common. Give adrenaline IMI. Initially just slow down the infusion, only stop if absolutely have to.
Malaria:diagnostic considerations in low resource settings– Amer Jaffal(Lesotho)
Half of the worlds population is at risk of contracting malaria
>400 000 deaths per year(>92% Africa)
Why is this a tricky diagnosis: nonspecific symptoms.. fever chills, LOA, headache, vomiting, weakness.. sounds like gastro!
Blood: pallor, end organ effects
Breathing: acidotic breathing
What are the 3 main ways of diagnosing?
Clinical: problematic.. inaccurate in 50% – results in over diagnosis.(only 50% diagnosed this way don’t have malaria)
Microscopy: Thick(pick up parasite) & thin(identifies species) blood smear
Problem: needs expertise & microscope! If negative then repeat every 12 hrs x 3! Time consuming. False positive with very high parasite counts
Overdiagnosis results in high cost.($84mill in South Sudan)
Rapid tests– antigen based tests..(multiple different ones, speaker compared options)
pros: minimal expertise, no lab needed. results in 15-20mins., no need to for cold chain,
cons: false neg in pts from non endemic areas, false pos when repeat too soon in next few weeks.
Best option in low resrouce
Should we abandon microscopy? Cant get species & parasitemia from Rapid.
Use it to monitor response
Use in areas of high relapse
No test that distinguishes between asymptomatic parasitemia + other disease vs severe malaria
Very good at telling difference between above.. malaria retinopathy: perimacular whitening, hemorrhages with central whitening. Low resource iPhone options
Part 3: Emergency care over the edge
Life after being an EC doc– Melanie Stander
Dr Melanie Stander is currently the Emergency Medicine Manager for Mediclinic South Africa. Mel is instead taking a broader approach to include all of the Emergency Care providers and giving some broad concepts on how to keep focused and passionate about your career, even when patient care is not part of your daily activities.
Burnout is something that we are seeing more often in South African EM, and contributes to egress from the profession. It is essential to examine the specific situation in South Africa in order to keep Emergency Care providers in the system. More research into this is needed.
Mel argues that it is essential to develop other career pathways for Emergency Care providers to ensure that future leaders can move into these positions towards improving our systems, managing them effectively and building resilience.
Bullying in the EC– Lucy Hindle
Lucy from bad_EM talked on Adults behaving badly, aka bullying in the worplace. Lucy works at Chris Hani Baragwanath hospital. If you don’t know where that is google it. It’s one of the biggest and busiest trauma hospitals in the world.
Bullying can be thought of any repeated behaviour that causes harm. We probably have all experienced this, and some of us will have been responsible for it.
Harrassment is different in that it is targeted against some characteristic that a person may exhibit(e.g. gender, sexual orientation etc.).
Lucy points out that if we don’t stand up to bullying and haarrasssment, call it out and take a stand then we are partly responsible for allowing it to continue. It’s worth a reminder of David Morrison’s words.
Medicine in particular has problems with bullying and harrassment. Juniors often require approval from seniors for career progression, or we exist in a culture of silence when people are scared to speak up.
Worldwide data shows high numbers of junior docs reporting bullying(interestingly the Canadians have the lowest rate– make up you’re own mind why– but even then it’s just under 50% which is still sky high).
This is a problem because bullying does NOT MAKE PEOPLE BE BETTER DOCTORS! Seriously, this is important, if bullying actually improved patient care then maybe we could excuse it, but it really doesn’t. It makes clinical care worse and probably encourages people to leave our speciality, or even medicine all together. Bottom line is that we need to speak out and speak up whenever we encounter bad behaviour in the ED.
Staff safety against attacks– Shaheem De Vries
EMS are not specific targets– it is a product of larger system or community concerns. The communities within which the attacks are taking place, are dealing with these attacks themselves– against their children and families. Standing behind EMS, is really simply saying and protesting what the communities have always been saying.
Shaheem discussed anti-fragility which refers to a dynamic state where EMS respond to and adapt to the attacks and still provide the service because of passion, despite safety concerns. Every time the EMS uniform is donned, EMS make an explicit silent decision to place themselves in harm’s way to serve the community.
The Ethics of volunteering– Amelia Pouson
Amelia makes the case for 4 rules for medical volunteering in less advantaged medical settings. She apologised in advance for the language…..
Rule 1: Know your shit. In other words be good at your job before you volunteer, if your’re not good enough to do a particular job in your own country then you won’t be safe doing it as a volunteer. Ask yourself if you trust yourself to do the job. Know the limitations of what you’re teaching, EBM may not be that EBM in a different setting. Do teach whenever you can.
Rule 2: Give a shit. If you don’t care, or if you care for the wrong reasons then don’t go. There is no point taking your problems somewhere else. You need to care, but that’s not everything. Just being passionate about a task is not enough, you actually need to be able to deliver. Remember that if you’re not careful you can cause harm.1
Rule 3: Shit Happens. Bad things happen, so do you have a plan for when things go wrong. Ask yourself if you have a plan if the circumstances around you (or back home) suddenly change. If you don’t have a plan for when things go wrong then you risk making everything worse for you and for everyone else around you.
Rule 4: Don’t be a shit!: Poorly planned volunteer projects can make things worse. If you just dive in and out without the right reasons you’re not a good person. Here’s a great question Would you go if you could not take a camera? If the answer is no then maybe you’re doing it for the wrong reasons. Travel humbly and kindly. Ask yourself if your intentions are honorably (remember what John Hinds said – it’s the same here).
This blog and the other 2 in the EMSSA series were cocreated by a range of authors. Apologies if I’ve missed anyone! By co-created we mean that we all logged into the same online document and wrote the blogs as they happened. We used the Papers function on Dropbox. This appeared to work really well for capturing the conference narrative. Thanks to all.
As with all conferences the opportiunities for networking and interacting with new friends and colleagues is a real draw. Last night the conference organised a Braai in the middle of the bush. A great night had by all with some fabulous food, company, wine and dancing.
Simon Carley MB ChB, PGDip, DipIMC (RCS Ed), FRCS (Ed)(1998), FHEA, FAcadMed, FRCEM, FTACC, MPhil, MD, PhD is Creator, Webmaster, owner and Editor in Chief of the St Emlyn’s blog and podcast. He is visiting Professor at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. He is co-founder of BestBets, St.Emlyns and the MSc in emergency medicine at Manchester Metropolitan University. He is an Education Associate with the General Medical Council and is an Associate Editor for the Emergency Medicine Journal. His research interests include diagnostics, MedEd, Major incidents & Evidence based Emergency Medicine. He is verified on twitter as @EMManchester
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