Well hopefully you all had a lovely evening and possibly even managed to go for a run along the coast to celebrate having functioning livers!
I got into the spirit of things with a quick morning run up north, but sadly the weather here wasn’t quite up to par with the southern coast. Nevertheless, I’ve left my shoes drying in a corner and have had a great day watching the RCEM CPD conference from rainy Virchester.
Here are some of the things we’ve learnt from day 2!
Maurice Ellis Lecture
Dr Chris Moulton has been an EM consultant for a while now and is well known amongst emergency medicine clinicians in the country, but particularly here in the north west where most will have a story (or several) about things they’ve learnt from him over the years. Chris is the lead for GIRFT (Getting It Right First Time) for EM and gave the Maurice Ellis Lecture at this year’s CPD conference about his work setting up the GIRFT programme and what it’s all about.
From Chris’ work have come (amongst other things) some truly scary statistics demonstrating a very clear association between delay to admission from the ED and mortality. We’ve covered his team’s January 2022 paper here on St Emlyn’s and the college has continued to fight to promote these findings at a high level in order to make change. GIRFT also continues to look at ways to reduce time and costs for both ED and pre-hospital teams, for example through the use of clinical hubs to offer alternatives to ED, but these measures rarely exist in practice.
Chris’ talk was fantastic and it was a pleasure to hear him speak as usual.
The main takeaway for me from Dr Patel’s talk on diabetes was that I know a lot less about diabetes than I should. One top tip was a caution that devices such as Libre, which many patients with T1DM have, measure glucose in interstitial fluid rather than capillary blood levels. It’s ok to use these to monitor levels in ED rather than serial finger pricks, but if the patient is shocked or dehydrated then the reading may not reflect the blood levels. If it doesn’t make sense clinically, correlate with a finger prick CBG!
Most clinicians are worried about resuscitative hysterotomies and cardiac arrest in pregnancy in the emergency department based on the research Dr Ganga Verma did before putting her talk together. Her key tips are to call obstetrics and neonates as early as possible, designate someone specifically for manual uterine displacement (no tilting!), and think about resuscitative hysterotomy so it’s in your mind (oh and share your mental model so everyone else has it in theirs too!). Joint training and frequent simulation can be key in allowing the teams to come together and work out where potential issues may arise before it happens for real. Sim also helps to build a successful relationship with your obstetricians and neonatalogists.
A great talk also from Dr Srinivasan Narayanan on sickle cell disease with some good points here…
After a quick break we moved onto the paediatric stream. Dr Ffion Davies and Dr Clarissa Chase took us through an alphabet song of paediatric emergency medicine. This was a brilliant half hour of some top rhymes (with surprisingly less dubious ones than I was expecting!) and it was so impressive that Ffion and Clarissa were able to put this together. An A-Z of incredible nuggets, from ALTEs and BRUEs, to giving children the illusion of choice (shall we look in your ears first or mouth first?), to highlighting the HEADSSS assessment for children presenting with mental health issues, to ketamine (obviously), to zero compares – there’s no other specialty these two consultants would rather do.
Paediatric mental health presentations are increasing and many clinicians feel they don’t have the right knowledge and skills to give these patients the care and support they need. There is a big driver for change, and nationally by 2023/24 100% of paediatric emergency departments should have in-house CAMHS liaison teams which will be hugely beneficial.
The human dimension
An important and highly topical session after lunch, with some heavy-hitting talks on refugee health, modern slavery, human trafficking and county lines.
Dr Jane Hunt took us through refugee health, highlighting some of the individual and systemic barriers to healthcare for this population, together with some of the things we as clinicians in the emergency department can do to help overcome these. The ED is the commonest destination for refugees with health problems and it’s important we recognise that their background, route taken, and possible pathologies will be different to those we’re used to in the majority of the patients we see. Jane advocated that we try to put ourselves in their shoes – what has happened before, during and after their migration to the UK, and how might their physical and mental health be affected as a result?
Consider the full picture, there may be untreated chronic health conditions or communicable diseases to think about as well.
Next up was Ms Rachel Witkin, explaining terms such as modern slavery and human trafficking, and how we might see signs of this in patients in the emergency department. We need to consider this exploitation in patients presenting with signs of abuse, malnourishment, untreated injury, sexual health issues, late or failed appointments for pregnancy, or those who appear frightened/withdrawn/anxious or hesitant to seek help. The UK is in the top 3 countries worldwide for people in modern slavery, with nearly 13,000 cases reported to the home office in 2021.
Finally, Duncan Evans talked about county lines, which is a term used for organised illegal drug-dealing networks, who frequently (despite the name) don’t operate across county lines. With Covid-19 restrictions, there was a 25% increase in children being exploited into these networks to move drugs as the rules didn’t apply to children during the pandemic. Drugs nowadays come in more colourful forms and even sweet-like preparations or packing, so heavily more marketed towards younger people and children. As clinicians in the ED we have a responsibility to look for opportunities to protect vulnerable adults and children before they become immersed in county lines.
Duncan advised we have a look at some videos they have on the National County Lines Coordination Centre YouTube channel for more information on topics such as how country lines work, and the national referral mechanism.
Pearls and pitfalls
The last session of the day discussed the role of the legal system, and some of the ways we need to adjust our practice (particularly around documentation and communication) to ensure that in the event of any complications or adverse events our decision-making is clear to those investigating, such as the medical examiner or coroner.
Dr Alan Fletcher, National Medical Examiner (and EM consultant) not only talked more about the role of the medical examiner in assessing the healthcare process and identifying areas for change, but also highlighted the risks of burnout amongst emergency physicians and the chance for us to get off the shop floor by looking into becoming an ME ourselves as part of our job plan. A lot of us have portfolio careers and being a medical examiner might be something to add to yours. It was great to hear his experience on looking into deaths as part of his role, and what he has learnt along the way.
Dr Julia Harris and Dr John Heyworth explained how witnesses work and reminded us to train and prepare ourselves before attending court. You may be asked to attend for three broad reasons – to be a witness to events, to be a witness to medical fact (i.e. as a professional witness in coroner’s court where you relay the facts of the case), or to be a witness to medical opinion (as an expert witness appointed to interpret the facts of the case using your expertise). It’s important to remember that you’re responsible to the court so provide a balanced report, be completely truthful, and keep within the scope of your expertise. You need to discuss any appearances with your indemnity organisation, and of course your trust’s legal team. If you’re looking to become an expert witness there are specific courses to attend, so have a look for those.
A great end to day 2 with much reassurance that actually continuing to provide good emergency medical practice in our departments will stand up to any medicolegal tests. The opinion from the panel was that much litigation can be avoided with good communication with your patients and families, and documenting just a little bit more than we normally do.
Hope you’re all ready for the final day!