RCEM CPD conference 2024 review

This week I’ve been in Newport, Wales at the annual RCEM CPD conference. Sadly amongst meetings and other commitments I’ve not been able to be here fotr the full three days, but with the help of colleagues (notably Dave Hartin) I’ve put together a few learning points below. I’m going to do the review in two parts with one specifically on the RACE session which can be found here.

Talks covered are listed below

• Gareth Grier delivered the Maurice Ellis lecture.
• Adrian Boyle delivered the presidential address.
• Amy Owen and Non Evans presented on the the team voted best for training in EM for 2023.
• Ash Basu talked on excellence in EM training.
• Dr Rita Das talking about the history of race and medicine.
• Dr David Chung on Differential attainment
• Dr Sivanthi Sivanadarajah It’s the journey not the destination
• Regina Lopez on eye emergencies to look out for
• Dr Matt Jones on the use of Rapid Assessment and Treatment (RAT) in the ED.
• Ian Higginson (Higgi) updated on Crowding in Emergency Medicine
• Dr Sam Jones spoke on CYP mental health management.
• Claire McCarthy talked on the impact of minor injury services
• Prof Damian Roland on PEWS
• Dr Vicky Hughes talks on atraumatic headache in the ED.

Estimated reading time: 1 minute

Gareth Grier delivered the Maurice Ellis lecture.

He started with a note of respect to all of those who are working in very adverse circumstances around the world. We are lucky in many ways in the UK as EM is now unrecognisable from when Maurice Ellis started in Leeds.

The main focus of the talk was on trauma and specifically on head injury and haemorrhage.

Looking back to 2006 and head injury care.

1. Anaesthesia
2. Oxygen
3. CO2 control
4. Head up
5. Hypertonic saline
6. Loose collar
7. Take to Neurosurgery
8. Most importantly – care was dictated by neurosurgeons and this was a surgical disease.
9. And again – this is disease agnostic – in that everyone pretty much got the same recipe.

In 2024 we have a different approach. Some patients do indeed need surgery, but the majority are not the time critical extradural with a period of lucency. We can also now have a more nuanced approach to head injury management that is more pathology specific (though it is tricky).

In 2024 when we look back at the list above we are still doing pretty much the same, although it is now much more widely available with the better availability of PHEM.

That said, the outcomes from head injury are largely unchanged over 30 years, and that means that this disease is devastating for patients and their families.

So what do we hope that head injury management will look like in 2035?

Gareth talked about impact brain apnoea in hyperacute head injury the loss of airway and ventilation is almost certainly important in the early stages, and in the ultimate outcome of their head injury. This dysventilation is something we might be able to do something about to prevent a hypoxic axonal injury. The obvious solution is going to have to be early intervention and that means bystanders and the public, perhaps in the same way that we encourage bystander CPR we need to think about bystander airway and ventilation management in the immediate aftermath of injury.

Gareth played a video of telephone advice from the ambulance service talking through the removal of a biker’s helmet and opening the airway. Remember that lots of people are frightened of moving the neck of patients with head injury. Fair enough from a spinal injury perspective, but airway management is more important.

Interestingly there is research on biomarkers (detectable in saliva) such as MiRNA that can predict the outcome of head injury. Not ready for prime time but certainly an area of research that may prove helpful in the future.

We may also find specific treatments for the targeting of brain injury, but we are not there yet.

In terms of exsanguination, the science is moving forward fast. Increasingly it looks as though managing the coronary performance is vital in trauma management. It’s not just about volume replacement, but also about managing the pump. This reminds me of a recent conversation with other members of the London Air Ambulance and their experience on managing patients on ECMO in the post resuscitation phase during a more prolonged period of cardiovascular instability. This is not something we do in Virchester, but around the world it’s increasingly being used.

A great journey of science and experience from Gareth as the Maurice Ellis lecturer.

Adrian Boyle delivered the presidential address.

Times are tough, and the performance of emergency care systems is challenged. We do have more patients, but the issues of flow and more are causing very long waits in the ED. Notably the number of 12 hour stays in EDs is still very high.

The impact of this is felt on our workforce. We have high levels of fatigue, burnout, and unhappiness. RCEM is working hard to advocate for the workforce and it’s a big part of our work.

Interestingly, although the pressures are huge, the PIPP study showed that people still love EM as a job, but not the pressures, environment and culture that sometimes exists. The PIPP project is well worth a read as a study or on the RCEM website.

Individually we need to look after our colleagues. It’s interesting to see that vaccination rates for influenza are falling, the impact of which is obvious. Why this is happening is really interesting, although it’s unclear why this has happened.

The resuscitate emergency care program is how RCEM is influencing those agencies (Government/NHSE) to help them do the right thing for emergency care. RCEM has the expertise and we can be the voice of the speciality with those who can ultimately make the change happen.

A recent census of EM departments was presented and there are a few key messages. We are a young speciality and clearly under in terms of consultants. We suspect that there are 300 vacancies for consultants across the UK. However, the distribution of vacant posts is very uneven. Many of the MTCs have sucked in recent new consultants leaving gaps elsewhere and significant inequity for staff and patients.

Overall 10% of consultant shifts are delivered by consultants – which again means that we need more staff.

The paradox is that for those trying to get into training it’s getting harder as competition ratios ar getting tougher, especially in ACCS. My feeling is that those setting the numbers of training posts have not linked up to the fact that we have shortages. RCEM is aiming for an additional 100 training posts, and I think we do need that. As it currently stands it’s a tough argument that is not being heard, but Adrian and RCEM will be working hard to change this.

The PA question is complex. RCEM currently has no confirmed position, there is a SLWG looking at this and then council will review and come to a decision. Following council consideration, the results of the survey and the college position will be released. I am leading the SLWG and it’s not a job that we are going to rush. Rather we need data and options to present to council. That will frustratingly take longer than some would like, but as we have seen with the difficulties we have seen in other colleges, we want to do this from a data driven perspective and with proper consideration of all issues.

Amy Owen and Non Evans presented on the the team voted best for training in EM for 2023.

This was based on the GMC data from 2023, and the department is the Bangor Emergency Medicine department.

The clinical fellow scheme there has been running for many years and is really popular meaning that they get great applicants. Big lesson here is that trainees talk to each other and if you have a great program, it self-recruits! Looking after your trainees today, means sustainable and super trainees in the future too.

Key points.

1. A really good pre-induction process for the trainee to learn the department and the department to learn about the trainee.
2. As Bangor is a bit more remote, then helping trainees find things like accommodation is really important. Linking outgoing and incoming doctors really helps with this.
3. WhatsApp groups in the preinduction phase is really important.
4. The program really looks at supporting people not just in their work, but also aspects of their life with the department acting as hub to support their trainees in many aspects of their life.
5. Giving opportunities to socialise together really makes a difference.
6. There is a focus on the following which are the self-created values of the senior team.
   1. Teamwork
   1. Compassion
   1. Excellence
7. Summary
   1. Introduce new members to the department
   1. Prioritise learning for all
   1. Support trainees and fellows in and out of work
   1. Have fun!

What a great talk from a wonderful set of people. A lot of the ingredients of a great department seem to be quite simple, and achievable everywhere. We should all do the same.

Ash Basu talked on excellence in EM training.

Difficult to pin down. Also tricky to get good data as GMC survey comes out at the end of Winter, and Quality panels are done just after rotations.

There is a lot we can do, much of which is contained in the RCEM document Promoting Excellence document. I would argue that it’s a really good document, but sadly the audience were largely unaware of it.

Chris Fox talked on opportunities for global health training in EM.

Chris reminded us of the importance of remaining aware of neo-colonialism in some global health initiatives. It’s something that anyone working in this space should be very mindful of.

He has worked in a variety of settings, but more recently in Somaliland. There is one doctor/40,000 people (one of the lowest in the world).

Major learning points from his time in Somaliland

1. Different disease. Lots of TB and tropical diseases. Lots of snake and potentially rabid dog bites that we don’t see in the UK
2. It’s worth doing a diploma in tropical medicine before embarking on such trips (you need to know what you are doing)
3. Practicing without basic blood tests, scanners and other investigations is really tough and requires significant adaptation.
4. There is no established EM doctors in Somaliland.
5. The standard of local doctors is variable. Some are excellent already, others are still learning and often quite junior and thus exposed.

Major learning points from Kiev

1. Destruction of healthcare infrastructure a real issue.
2. Portable USS very helpful as a replacement for traditional imaging. A number of butterfly devices were donated to Eastern Ukraine to replace infrastructure.
3. Education can be an effective tool in global health (but beware of neo-colonial issues – don’t just tell people what we do in UK as that’s not helpful).

There are opportunities for RCEM clinicians to support global health programs, but they should be done wisely, with appropriate training and within the support of well established organisations.

More on global health from the St Emlyn’s team here.

As I was on stage for the next session, Dave Hartin, our good friend of St Emlyn’s took over the note taking for the RACE section. This was an amazing session and has been blogged here.

akes and encountering setbacks might be a painful and unavoidable part of the learning and the journey. When the going gets tough take a break but don’t give up – and make sure you frequently go back to looking in the mirror because no matter who you are, there will always be one person that you can influence – and that is yourself.

Regina Lopez on eye emergencies to look out for

Look for the 5-Ps. If your patient does not have these, then the red eye is probably not that serious.

1. Pain
2. Photophobia
3. Poor vision
4. Pus in the anterior chamber
5. Pupil abnormalities

Vicky Hughes talks on atraumatic headache in the ED.

Dr Hughes has an extensive experience in EM and PHEM and now works in WestWales (and showed some stunning photos of the area which made me want to move there)

Key points

1. 2% of ED attendances are primarily headache
2. 1-4% have a life threatening headache
3. At the moment we don’t do that well in terms of giving a diagnosis, and yet that’s not what we do as the majority go home without a diagnosis. We are also not great at removing the pain (which is always important to patients).
4. Think about treatments for the following for primary headaches. Please avoid opiates in this group.
   1. Migraine –
      1. Tryptans
      1. 900mg Aspirin
      1. Paracetamol
      1. Metoclopramide
   1. Tension headaches
      1. Simple analgesia and advice
   1. Cluster
      1. Sumatriptan
      1. If red flags be careful and get advice
      1. High flow O2
5. For secondary headaches then there are many, but let’s focus on the following.
   1. Medication overuse headaches (MOH) are quite common, and especially amongst migraine users.
   1. SAH is something we must actively seek as it’s one we don’t want to miss.
      1. CT is mainstay of investigation
      1. My view – LP less commonly done, and probably needs a discussion with the patient and a risk assessment.
      1. Remember that thunderclap may be seconds to minutes, although if a true thunderclap headache more likely to end up with a neurosurgeon
      1. 10% miss rate in ED
      1. 30-day mortality of 50%
      1. Risk of rebleeds (so really important to spot the sentinel bleeds)
      1. CT at less than 6 hours with a good scanner and a good radiologist is pretty good.
   1. Giant Cell Arteritis
      1. Older patients
      1. Get a CRP/ESR
      1. Refer as needed

Ian Higginson (Higgi) updated on Crowding in Emergency Medicine

Higgi is one of the RCEM vice presidents and has extensive experience in leadership and management, He’s also been deeply involved in developing college policy.

Key points.

1. No real definition of crowding. Many people use flow as a measure but it’s mnore complex than that.
2. The impact of crowding is bad for patients, staff, morale and everything else.
3. The controversies….
   1. Some people now accept it as normal and thus inevitable. We must not accept the normalisation of what is deeply abnormal and dangerous (for everyone)
   1. Funding is an issue. There is a strong linkage between NHS funding and crowding. The UK is spending less GDP on healthcare.
   1. We centralise hospitals in the UK, and we have fewer beds. That creates pressure cooker dynamics with the concentration of patients in small areas.
   1. Crowding is not an ED/EM issue. It’s a whole system issue and thus the solutions need to be whole system too. RCEM is working hard to do this through the policy team and we do appear to be listened to (though those listening don’t always agree/believe).
4. Should we manage or mitigate.
   1. There is a paradox about writing on how to manage crowding when we don’t believe it should happen!!
   1. So RCEM have published guidance – but we are grumpy about it and constantly tell people this.
5. A model for crowding, is to invert the traditional throughput model. Largely because traditional solutions of demand management simply don’t work
   1. Think output first (the back door)
   1. Then think about throughput (what the ED does)
   1. Then think about input (demand)
6. The 4-hour standard is deeply flawed, but it’s probably the best single measure at the moment that we can engage with and which other understand. We are all very worried about the long stays, typically the complex medical who are most at risk of harm. 12-hour waits are unacceptably long at the moment.
7. Where to put patients is controversial too when we are crowded
8. Escalation is such a common term, but in many cases escalation does nothing. It’s just a term that creates activity and chat, but no action. Escalation has to mean something, and that means action. Escalation in itself is not an action, it’s just words.
9. There are some other elephants in the room
   1. ED productivity will come under scrutiny
   1. Cultre and behaviours need review in many areas
   1. There is a lack of accountability for crowding effects. We carry the risk, but we are not empowered to make the big changes that will make a difference.
   1. Out of hours is still an issue.

Claire McCarthy talked on the impact of minor injury services

Specifically, she asked to consider whether they help crowding or do they deskill the workforce

1. Minor injury units are popular and have expanded a lot in the last two decades
2. It does mean that our trainees see fewer minor injuries. This is potentially a problem as minor injury management is part of the curriculum, and it’s also a really rewarding part of our practice.
3. MIUs are not 24/7 and so we end up with our trainees seeing minor injuries at times where supervision and teaching may be compromised.
4. MIUs appear to be popular with patients.
5. It’s both doctors and nurses who have deskilled in minor injury management.
6. In my practice I mostly see minor injuries when working in paediatrics as there is no paediatric MIU on our site. That keeps my skills up and allows our trainees to see these patients, but this situation is not universal and I’m aware of some rotations where exposure to minor injuries is minimal.

This made me think about how we train our staff. In Virchester we rotate our trainees through resus by identifying who is allocated to that area on the rota. Should we do the same for minor injuries and rotate a doc through those shifts on a regular basis? Something to certainly think about

Dr Matt Jones on the use of Rapid Assessment and Treatment (RAT) in the ED.

This is a model where patients are seen at the front door so that they can be appropriately sorted and patient care can be started early in the patient journey.

My view on RATs in the past has been that RATs are a great idea, but sustainability is an issue, and the data I’ve seen in the past suggests that they don’t make a difference to length of stay or crowding.

Key points.

1. RAT systems can front load investigations
2. Having consultants in the RAT can not only start investigations early but also prevent unnecessary investigation. Arguably not doing investigations is more important in terms of efficiency.
3. RATs can work in terms of getting things done, but that may not lead to less crowding.
4. There is a potential loss of training opportunities if patients are already pre-seen by a consultant in the RAT.
5. It can cause bottlenecks in flow.
6. If you start a RAT it might have a short term effect, but the system will recalibrate and crowding will return, but with fewer in the moment options to manage the peak and troughs of flow.

So overall it can be done, but it’s not a panacea for crowding. It’s probably better for most patients, but not all. It’s not a magic bullet for crowding. The patients who benefit the most are the low risk/acuity patients, and those aren’t the ones who we are most worried about.

Prof Damian Roland on PEWS

This is an NHS England project to provide a unified approach to charting for paediatric patients. Although it’s an English project it’s likely that it will influence approaches in the other UK nations.

Key points

1. PEWS scores are not perfect and that leads to ‘Fake PEWS’ which subsequently devalues it’s use.
2. That said, having a single approach (even if imperfect) is a great way to train, learn and calibrate care
3. Scores are not everything. Clinical practice should be able to incorporate these four elements.
   1. PEWS score
   1. Specific concern
   1. Clinical Intuition
   1. Parent concern
4. That said, a PEWS of >5 does seem to have clinical significance and should be taken seriously.
5. There is an issue with some of the elements of PEWS. BP is tricky to do, and things like parental concern or temperature may flood the process. And yet they may be really important.
6. How we use scores is dependent on location, particularly when we think about need for intervention. So a score needs to link to an intervention that is specific to which service/department we are looking at (example would be that PICU vs. prehospital where a ‘no concern’ action may represent very different patients).
7. The aim is to get a standardised chart for paediatric emergency medicine, but we are not there yet – watch this space. Pilot sites coming in the next year.

Dr Sam Jones spoke on CYP mental health management.

This is certainly an area that we see a lot of in PEM, and departments should be able to manage it. Referrals to mental health from CYP sre on the increase. Some of this is attributed to COVID, but the data suggests that it has been rising from way before then.

70% of mental health attendances are female, and have a higher prevalence of neurodiversity. 62% are mental health concerns alone, but 40% also have a physical component and will therefore continue to attend paediatric departments. So we must know what to do, and that’s not just us. Traditional paediatric training did not have a lot of mental health in the curriculum, but that has changed with the new curriculum, but that may take time to trickle through to practice.

We can build early mental health reviews into the ED, but there are sometimes issues with making this 24 hours. 20% of children come in after 8pm, and children’s mental health services are not always available then.

A key theme here was to collaborate, advocate and educate to make our services better for CYP with mental health needs. The message here was that we can certainly make models better through developing collaborative networks.

Summary

Another great conference, with some excellent speakers. The highlight as always was meeting up with old and new friends, and with a special mention to Rob Perry. I’ve known Rob for years and it was absolutely fantastic to see him take the stage as the new RCEM Vice President for Wales.

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