RCEM Annual Scientific Conference 2024

It’s always great to be back at an RCEM conference. Whilst Iain and Liz are in Sweden at #tactrauma I’m here in Gateshead for a fabulous three days at the annual scientific meeting. I can’t cover the whole event but I have been able to pick out a few highlights below.

President’s address

Adrian Boyle kicked off the conference with a state-of-the-nation address. In the last year, RCEM has been incredibly active both in public and behind the scenes. The main thrust of policy is the resuscitate emergency medicine campaign, which you can read more about here.

Five Priorities for UK Governments to #Resuscitate Emergency Care lays out what UK governments must focus on to tackle the crisis, improve patient care, retain staff, and prevent harm. The five priorities are:
1. Eradicate overcrowding and corridor care for patients
2. Provide the UK with the Emergency Medicine workforce it needs to deliver safe care
3. Ensure our NHS can provide equitable care to emergency patients
4. Focus on evidence-based interventions to tackle overcrowding
5. Introduce meaningful and transparent metrics to facilitate performance and better outcomes for patients

Unlike many other organisations RCEM is strong on seeking solutions, not just complaining about the status quo. The recent workforce census and subsequent recommendations is a good example. That document shows huge discrepancies in the number of consultants (and other staff) between departments. We are seeing more and more consultants (and other staff going part-time or retiring early. RCEM estimates that there are 180 empty posts across the UK at the moment. There are clearly gaps, as 35% of departments have less than 16 hours a day of departmental consultant cover.

You will also be familiar with the comparators of burnout and sexual harassment against trainees, where EM scores highly (i.e. badly). So, lots of work is still needed on workforce and culture.

The Darzi review is another key document that RCEM has contributed to. The key thing for us is that it explicitly accepts that long waits harm patients and that the working experience is poor. We know this, but for the first time, this is a true acceptance at the government level that it actually matters. This is a real change compared to the last government, which was pushing for the following three overarching themes. What these will look like in reality is yet to be seen.

Hospital to community
Sickness to prevention
Analogue to digital

Adrian also told us about his own brush with health services earlier this year when he broke his hip, which is still causing problems. That sounds nasty, and we wish him the best in a full recovery.

Panel discussion on the future of emergency care

Adrian joined Sarah Scobie (Nuffield Trust), Jukian Redhead (NHSE), and Rebecca Thomas (The Independent newspaper). There was lots to talk about, but the main themes were…

Waiting times have been getting worse for over a decade. It’s not just COVID, and it took a long time to get here. The obvious follow-on is that it may well take a long time to turn things around, too. There are no quick fixes.
Long waits disproportionately affect admitted patients, especially the elderly. We know this, and there is really good data to back it up. It’s almost certainly a contributor to the harm that results.
10% of people who are in their last month of life get admitted through ED in that last month. Many are elderly. Perhaps an area for support from palliative care services.
Rebecca Thomas (worth a follow on X) gave a really important perspective on how the public see our problems. Stories matter, personal patient experience matters, and narrative matters. We are so familiar with waits and problems that the public may only notice when something is ‘different’. We are strong believers in the importance of stories/narration in getting messages across, and this resonated with us. I guess statistics and data do not speak to us in the same way that personal stories do.
Julian Redhead reiterated some of the earlier themes: major problems with crowding and mental health in a system that is asking more of EM in terms of diagnosis, treatment, and discharge.
We often consider social care a problem of crowding, and it’s certainly a factor, but the numbers suggest that people like us are actually doing more each year (but the system is just not keeping up with demand).
Julian stated that the current government wants to return to NHS constitution standards, which means a return to the 95% 4-hour target—something that we are a long, long way away from at the moment.
Worryingly, Julian Redhead seemed to suggest splitting off EM from Urgent Care, with walk-in patients going to UTC rather than the ED. How that actually looks is unclear. Of course, there would be big implications for organisations, staffing, and training.
We also heard a lot about innovations and examples of good practice, but what I think is needed is more on how we develop this through more academic capacity and plans/innovations in scaling good practice.
Questions from the floor looked at workforce planning and whether we have the right number of training posts. There are real problems in managing a long-term workforce plan and supporting juniors. Currently, the block is getting into training, which is used to manage a potential block later on (if there are no consultant jobs at the end). My question would be whether trainees prefer to be blocked at the entry or exit points. Or maybe that’s not a good question at all as neither scenario is a good choice.
Some discussion about the silo nature of emergency care. Relationships with in-patient specialities are a common concern, and work needs to be done to improve that at the college level, locally, and with national support.
Targets are always of interest. There appeared to be consensus on a target specifically for 12-hour waits. Adrian suggested a zero tolerance for 12-hour waits, which I agree with.

Cannabis hyperemesis syndrome

Chris Humphries talked on this increasingly common presentation to the emergency department. It’s certainly somethi ng we see a lot of in the emergency department in Virchester. There is an RCEM guideline on this as published on the RCEM website and also published in the EMJ (yay).

The classic presentation is the cannabis user with persistent vomiting. Often, it’s not as obvious as they arrive unless you dig into what might be going on. Drug use is often denied and something that you may have to look for. Patients will have cyclical vomiting, prolonged cannabis use (not defined) and relieved by cessation. The problem is that determining this in a vomiting patient is tricky (esp. the cessation bit). So we will often be unsure about the absolute diagnosis, so treat ‘suspected’ CHS rather than ‘I’m absolutely sure this is’ CHS. You may also hear about hot bathing/showers which is likely a specific but not sensitive sign.

Remember that cannabis can come in many forms including private prescriptions for pain etc.

Why it happens? We don’t really know. There are several proposed mechanisms but we just don’t know for sure.

In the UK, there is a lot of cannabis around, and ther is also a lot of cannabinoids. THC is the rpincipal cannabinoid, but there are others including things like Spice (which we also see in Virchester, though less than we used to). The bottom line is that there a lot of drugs around in the UK, and there may be consequences that we need to know about.

CHS was only described in 2004, so pretty recent, and the evidence base is pretty small with a single systematic review and a few small RCTs. One small issue with the evidence for some drugs like Haloperidol is that the trials used the IV route (which is not licensed in the UK).

In terms of treatment the current recommendation is to use haloperidol as a first line agent. There’s a good review of the key paper here on REBEL EM. It also works for gastroparesis. Chris’s experience is the same as mine, Haloperidol really works for many patients and is much more effective than drugs such as ondansetron. That does mean that RCEM recommend IM rather than the trial evidence of IV, but it does seem to work IM.

Opioid toxicity.

Ruben Thanacoody talked on the recent RCEM/NPIS guidleline on opiod toxicity. This is a big issue as opiod deaths are common and account for over 50% of toxicology deaths in the UK and worldwide. No doubt that you are familiar with the use of naloxone and other drugs to relieve opioid toxicity, but I often see this done quite badly. Key aspects of the guidelines to remember are

Polypharmacy is very very common in opioid toxicity. Many of the additional drugs can cause resp depression.
Good quality basic care and the use of naloxone remain the main
IV is much better than IM for naloxone administration. IM takes too long to work effectively in many patients.
IM naloxone at discharge is not recommended (shorter half life than some of the opiod drugs)
Little data for IO naloxone (but my personal view is that I think it should work – but there is little evidence here).
Try and avoid putting patients into withdrawal. So a little and often naloxone is a sensible approach. Aim to support respiration rather than full awareness.
Excessive use of naloxone will lead to withdrawal but can also cuase cardiac complications including cardiac arrest.

New synthetic opioids (NSO)

Simon Hill from Newcastle talked on this emerging field as we see increasing numbers of opiate toxicity from drugs which have significantly different pharmacokinetics and characteristics to the traditional heroin and presciption medicines. Some of these are really long acting which can be a huge problem for us with regard to discharge.

Nitazenes
Brophine
Fentanyl related drugs (e.g. carfentanyl)
Others (e.g MT-45)

There are a significant number of deaths. In the UK, 2023 there were 65 in the first 6 months, and increasing numbers seen in Scotland more recently. This is a concern, but nowhere near as bad as North America where use (and harm) is much more widespread. They are often very potent with high affinity and slow dissociation. These drugs are so potent that we now see ‘end of the needle’ toxicity which may be a clue to diagnosis. This also means that for naloxone much higher doses, and for much longer may be needed.

Polypharmacy is common. In the IONA study the average number of drugs identified was 7, the maximum was 30.

Novel Benzodiazepines

Emma Morrison from ,toxbase talked on novel benzos. Emma works in Scotland where drug and alcohol use are real problems. Early mortality is the worst in the UK and in Europe. 1172 deaths from drug use in 2023. These are preventable deaths, and often linked to poverty. The population is getting older too with more deaths in those aged over 55.

Benzos are often used in conjuntion with opiates and we know that this really increases the risk of death.

The new agents such as Etizolam and Bromazolam have been attributed in many deaths, but there are so many different ones out there and it’s constantly changing.. This may be becuase of the very long action for many of them, and they may be more potent too. So a similar message to the impact of NCOs. Chronic use may lead to really significant withdrawal syndromes too.

Interestingly Flumazenil may have a role with these drugs, but I think I’ll be speaking to a toxicologist about that before prescribing it. Emma was really positive about it’s potential benefits and quoted a few studies that suggest that the risk of prolonged seizures is actually low.

Free papers session 1.

Paul Adamson on the battle scrore (also known as the STUMBL score which is actually preferred by the original author) for stratification of chest injury in a regional trauma unit. Here in Virchester we are very keen. onappropriate treatment of chest injury as it’s a really significant cause of mortality and morbidity in our trauma patients. This study was effectivey a validation study of the score in a different and notably older population than the original studies. Interestingly the score ws less useful in this cohoert with many more patients with lower scores having complications (though a lot of this was due to a longer hospital stay which may be a function of age and comorbidity). This fits with my experience in Virchester.

Kelly Fernandes described her project on paediatric major bleeding in trauma. Great work from a med student. First thing to note is that classical signs of blood loss such as hypotension was not reliable (and in fact hypertension was found in some – though this could be a monitoring issue in kids). 54 patients iwere included n the study, which is not a lot, but this is thankfully a rare group of patients in the UK. Mortality in ths group was sadly quite high at about 14%, possibly due to the higher number of penetrating injury as compared to other centres (this was London data).

Alice Pearson talked on the use of ambulatory monitoring in syncope patients. This was a qualitative study involving 20 patients and 10 health care professionals receiving ambulatory monitors in a Scottish cohort. This is part of the ASPIRED RCT looking at syncope patients. The bottom line is that is that the ambulatory ECG monitoring devices are really well accepted by patients and staff.

Codey Simmons talked about cognitive load for clinicians perroming REBOA. The bottom line is that REBOA requires a lot of cognitive capacitywhich is not hugely surprising. However, this was done during simulation and so how transferable to the real world and real procedures the results are is questionable. I’m yet to be convinced about REBOA in trauma outside of specialised services, but I do think it may have a role in cardiac arrest (but more data needed).

Sarah Wilson talked on the use of a structured tool to detect aortic dissection. The ASES study is looking at a range of scores and this presentation was about the meta-analysis and systematic review loolking at scores to detect Ao dissection. It all depends on how you use the score, but the ADD-RS score, if combined with d-dimer may have a reasonable sensitivity, though we need more work. Specificity was not that great (so this may end up a screening tool. We need more data. THe Canadian Practice Guideline may have a sensitivity of 93% and specificity of 67% which is not too shabby.

The Climate Emergency

Sandy Robertson and James Walton spoke on what is arguable ther most important session of the whole conference. The climate emergency is here and we need to do something about it. s healthcare workers we have a particular need to get involved as we are very influential and healthcare itself is a msjor cause of carbon emissions. Sandy summarised the messages that we need to get out to people

It’s real
It’s bad
It’s us
Experts agree
There is hope

A part of this that we can all play part in is to work on making our EDs better. It’s interesting to see many colleagues be environmentally aware in their personal lives, but. assoon as they arrive at work they don’t think in the same way, and yet healthcare is a significant problem that we can do something about.

The Green ED project is a great place to start and I’ve asked Sandy to do more about it on the blog soon. Please check out the website and consider getting your ED accredited. It’s a great project, it’s saves money, leads to better healthcare and a more environmentally aware department. It really is win-win!