RCEM Annual Scientific Conference. Day 3.

RCEM Professorial lecture with Edd Carlton.

Edd kicked the day off with a lecture focusing on #dogma. Something that we are really keen on at St Emlyn’s after learning about #dogmalysis from @cliffreid

Ed spoke about a new made up classification, called Carlton’s classification of Dogma. It was a great way to think about how our views and opinions can get in the way of patient care, and especially around resus. He described four types of dogma

  1. Retrograde dogma- current damaging practice persists in the absence of evidence. An example would be the CoMiTED trial of the conservative management of traumatic PTX. It’s a really great trial, but so difficult to get people to engage as custom and practice prevents people recruiting. People believe that they know the answer even though there is so little evidence. TRhere is true equipoise, but clinicians are paradoxically totally certain about their beliefs. People are weird and irrational. This has been a real problem in Virchester where we have really struggled to recruit because in-hospital specialities don’t believe in it.
  2. Dissociative dogma – Generation of evidence as a defence mechanism to bias towards oour own practice.
  3. Anterograde dogma Practice persists but we carry on doing the same thing anyway. An example would be the persistent use of TXA in GI bleeds even though we know it does not work and may be harmful (although very seriously unwell patients were excluded so there is still some equipoise for those patients).
  4. Post traumatic dogma. All practice must change on the learnings from a single case – also known as the DATIX phenomena. This is incredibly dfrustrating but seems to be the over-riding method of change in the NHS. It’s rubbish and a terrible way to look at medical care, but really enthusiastically supported by NHS management systems.
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Stacy Todd on the PRONTO trial

This is a trial of point of care procalcitonin trial in sepsis. The results were shared in the room but are not allowed to be released yet, but watch this space and wait for the formal publication. The trial is looking at procalcitonin in an undifferentiated possible sepsis group. It looks at whether the addition of procalcitonin to NEWS2 could lead to a reduction in antibiotic use without changing 28 day mortality,.

You can read more about the trial here https://www.cardiff.ac.uk/centre-for-trials-research/research/studies-and-trials/view/pronto

We can’t reveal the results here, but we can tell you that they are very interesting and will have people thinking about sepsis and antibiotic stewardship for years to come.

Procedures and skills session

Chris Yap talked about plan A blocks as a development of the fascia iliaca blocks that we are all very familiar with. A poll in the session revealed that most people are using USS guided FIB blocks. Chris talked us through other blocks that we might be able to use and should probably train in.

  1. Axillary nerve blocks for wrist manipulations (hmm, a maybe from me)
  2. Rib blocks. Consider serratus anterior blocks for rib fractures (strong agree from me), and in some cases erector spinae blocks. I’m a strong believer in really actively managing pain in rib fractures as it is so difficult to them and also has a real impact on their mortality and morbidity.
  3. Intra-articular local anaesthetic agents can be used for the reduction of shoulder dislocations. I’ve done this a few times and it does work, but at the moment I’m mostly using sedation and opioids to manage these patients. Maybe I’ll think about this again for those patients in whom sedation might be a less than optimal approach (e.g. comorbidities, intoxication etc.)
  4. The other USS guided block I use quite a lot is the ankle blocks.

Chris suggests that we reconsider what blocks we consider learning and perhaps we may see a change in the curriculum as a result of proposed Delphi study.

Chris’s guide to blocks is based on an anaesthetic and prehospital colleague. Know these 4 steps, of which the third is the key one. I like this, a great way to practice and also to teach.

  • Know the nerve
  • See the nerve
  • See the needle
  • Do the block.

Preparation for high risk procedures

Dion Arbid (EM and PHEM consutlant) talked on HALO techniques which is something we’ve covered on the blog before on the links below. There was a lot of common ground (which was reassuring).

  1. Training for HALO procedures. Part 1: Background and psychomotor skills. St Emlyn’s
  2. Training for HALO procedures. Part 2: Personal Preparation. St Emlyn’sTraining for HALO procedures. Part 3: The Team.

Lateral Canthotomy skills

Lucy Clarke talked about cantholysis. This is something I’ve done quite a few times now. It seems that many people have a lot of fear around this technique, but it’s really straightforward. We are aiming to release the pressure in the retro-orbital space to avoid an ischaemic optic neuropathy that can be reduced if decompressed within 2 hours of onset. Personally I think 2 hours is enough to get an ophthalmologist out of bed if you need one, but if they are especially reluctant it’s reasonable for us to know how to do it too.

The title of the talk was whether to do a one-snip or two-snip technique. The preference was for a two snip technique. Also it’s not necessary to crimp/crush the tissues as this makes scarring worse. The two snip technique is a posterior cut first to the orbital rim and then a downward cut onto the canthal tendon. That’s the way I’ve always been taught.


HRH Princess Anne

It’s always a delight to hear from The Princess Royal as patron of the college. She once again produced a very insightful view of the current state of EM, and the highlioghts of the conference. Her main message was that research, conferences and communication are vital components of developing oiur speciality. She also highlighted that the college is a function of its membership and that together we can make great strides forward for our speciality and our patients.

Rick Body on shared decision making for chest pain patients in the ED.

This was early results looking at shared decision making for patients attending with chest pain. Early data suggests significant shifts in patient behaviours with many more choosing to go home. This could have an enormous impact on our departments as chest pain is one of the most common reasons for attendance and for admission. It’s early days, but this could be a game-changer.

The work uses the T-MACS score to define a probability of myocardial infarction and then uses three different methods to communicate that to patients and then come to a shared decsion regarding admission. Follow. upwill include safety, acceptability and conflict outcomes. I’m really excited to see the results when they finally come out.

Lightning papers.

Too many to mention, but great to hear about

  1. Reboa in non-traumatic arrest: raises BP, but we don’t know if it works (Oliver Salway)
  2. Flumazenil use in benzo OD: It was always a no from me, but new evidence suggests it may have a place to avoid intubation (Gregor Stark)
  3. Driving advice after TIAs: We are not good at this and need to do better. (Abdulrahman Taha)
  4. Frequent Flyers: People who use ED frequently are almost all a result of health inequality. (Bethany Turner)
  5. Nettle induced Urticaria Treatment Studies (NUTS study): The common nettle causes stings. This was a PRCT of the use of the dock leaf vs. a lettuce leaf to relieve pain. This is an awesome study designed to teach people about research. The bottom line – the ITCH and OUCH scores were the same. Without doubt a fabulous exercise in teaching research with a practical trial. Wonderful (Chloe Haigh)
  6. Balint groups for ST3 EM trainees. Our own Geoff Haynes and Dan Darbyshire from PED in Virchester spoke on the impact of these support groups. Early feedback is very positive and highly valued. Something others should look at. Sessions were impactful and made participants feel more self aware and were a vital emotional support tool. (Geoff Haynes)
  7. Factors affecting cardiovascular instability after PHEA. I’m a bit biased as Abi was my med student on this project with the North West Air Ambulance Service. She did a fantastic job looking at HEMSBASE records and then used logistic regression to look for factors that might predict hypoxia or hypotension. Interestingly the only factor that flagged was age, but a further analysis showed that this is likely due to other factors that were not included in the model. There is further wotk to come here, but Abi has done the hard work in developing the model that we can use to look at these and other conditions. (Abigail Laycock)
  8. Health inequalities in EM: This study showed that social prescribers can really help multiple attenders in the ED. So we may not be the people to directly help these patients with their social problems, but we can signpost and support the referral process.
  9. Paediatric did not wait patients: Obviously a significant safeguarding wuestions when this happens and most places will (should) have a guideline on how to manage it. Bottom line was that in this audit documentation was not great. It has led to changes inpractice as all DNWs are now reviewed the next day. (Osian Newby)
  10. Can ED clinicians interpret CT scans with AI assistance? Basically the AI did OK, but there are caveats (for example it was not great at detecting mass effect) . AI rmay help us extend our skills into CT interpretation to detect serious pathology. Although it may not yet be ready for primer time I think it’s only a matter of time.
  11. Do thrombolysis rates for intermediate High-Risk PEs vary? This study showed that there is significant variability in the rates of thrombolysis for this condition, especially with more half dose thrombolysis being used in DGHs. There was more bleeding in the full dose thrombolysis group (23%) (Zara Rahman)
  12. Diagnostic of alternative biomarkers to detect acute aortic syndrome: A difficult to diagnose condition as several studies have shown. This systematic review looked at whether biomarkers might help in the diagnosis. The bottom line is that there are no good studies that show any alternative biomarkjers being any better than d-dimer, which itself is not that great. (Joshua Wren)

Looking after patients and staff

This was a fantastic session at the end of a busy three days. We had four great talks from super speakers/

  1. Prof. Rick Body spoke on compassion in emergency medicine. This is something we have covered on the blog before and is a really evidenced based topic. Compassion is clearly important in EM as it’s much better for patients and for staff. If we are in a state where we can offer compassion then everyone benefits, but that is hard when we work in difficult circumstances. That means that it is really important to try and look after ourselves as well as we can. Rick also described this experiment using Priests and which showed that even priests who have just prepared a sermon on the Good Samaritan will not help someone in need if they are under time pressure. In the ED we are always under time pressure and so the system is almost designed to diminish it. Rick also spoke on what patients actually want from us. Yes pain relief is important but so are other basic human needs such as an explanation, information and time; all things that go with compassion and which are lacking in our systems. Lots to think about in this talk about how we can avoid compassion fatigue and do better for our patients, ourselves and our colleagues.
  2. Dr. Andrew Tabner from Derby spoke on the use of body worn cameras in the ED. He presented a nice study that looked at patient and staff views on using them. Overall there were very positive responses, but in reality they were not worn as often as the enthusiasm in the survey suggested. That said I think we will see more of these in the future to reflect similar trends in other emergency services.
  3. Dr. Olivia Donnelly is a clinical psychologist in Bristol who talked about supporting staff and how resilience is a team gain and not some personal attribute that can be assumed to be present. There was a strong theme here that looking after yourself is paramount if you are then going to be able to effectively help others.
  4. We finished with a fantastically interesting talk from Dr Joanne Sutton Kline and Dr Alex de Little (Sonic artist and Uni lecturer) who are collaborating on a wonderful project on sound in the emergency department. It’s a qualitative project examining the experience of patients and staff with the sounds that surround us every day. I went into this thinking the answer is to simply turn it down/off, but I could not have been more wrong. Although early days the complexity and variability in what sound does, how we interpret it, how it affects us and patients is simply amazing. I learned a lot in this talk and want to hear (no pun intended) a lot more as I love it when research challenges my prior beliefs. It’s also a great example of collaboration between two quite different disciplines that together are greater than the sum of their parts. It’s clearly a rich area of research that is so much more complex and interesting than simply measuring decibels.

So the final day of the conference was another great day. We hope you’ve enjoyed the updates, but in truth it’s never as good as actually being here. So if you can find the time and the funds to get there please do consider coming along next year. The next big confer

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References and further reading

  1. Alan Grayson, “A St.Emlyn’s fascia iliaca block update.,” in St.Emlyn’s, January 22, 2016, https://www.stemlynsblog.org/fib-virgil/.
  2. Simon Carley, “Serratus Anterior Plane Blocks for rib fractures in the Emergency Department,” in St.Emlyn’s, May 24, 2024, https://www.stemlynsblog.org/jc-serratus-anterior-plane-blocks-for-rib-fractures-in-the-ed-st-emlyns/.
  3. Simon Carley, “Training for HALO procedures. Part 1: Background and psychomotor skills. St Emlyn’s,” in St.Emlyn’s, April 2, 2023, https://www.stemlynsblog.org/training-for-halo-procedures-part-1-background-and-psychomotor-skills-st-emlyns/.
  4. Simon Carley, “Training for HALO procedures. Part 2: Personal Preparation. St Emlyn’s,” in St.Emlyn’s, May 11, 2023, https://www.stemlynsblog.org/training-for-halo-procedures-part-2-personal-preparation-st-emlyns/.
  5. Simon Carley, “Training for HALO procedures. Part 3: The Team.,” in St.Emlyn’s, July 29, 2023, https://www.stemlynsblog.org/training-for-halo-procedures-part-3-the-team-st-emlyns/.
  6. Stanford compassion experiment. https://sparq.stanford.edu/solutions/take-time-be-good-samaritan

Cite this article as: Simon Carley, "RCEM Annual Scientific Conference. Day 3.," in St.Emlyn's, October 12, 2024, https://www.stemlynsblog.org/rcem-annual-scientific-conference-day-3/.

Thanks so much for following. Viva la #FOAMed

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