It’s the second time I’ve been to the Northern Emergency Medicine conference, this year held in the sunny city of Durham. I say sunny… I needed my jacket.
Last year’s programme was great and included some fantastic speakers, including our very own Simon Carley – he wrote an accompanying blog to his talk on the top 10+1 papers of 2016, which you can read here. Also the legendary Ross Fisher who gave a fantastic presentation on paediatric trauma. This year we also had a speaker on the list in the form of Alan Grayson, but more on that later! The talks this year were varied and very interesting. A great programme and a conference I’m sure I’ll be back to next year. Here’s the summary!
RCEM President Taj Hassan kicked off proceedings with a talk on the last 50 years of emergency medicine, He highlighted the great job the college has done in recruitment of members, growing from just 9 members at inception, to now over 7,500. Taj also talked about the RCEM Vision 2020 and the work the college has done to try to improve staffing, systems, and support for departments across the country. There are plans for dedicated EM leadership development programmes for trainees, and also discussion ongoing to support current, and create more fellowship schemes in geriatric/prehospital/humanitarian emergency medicine and other complementary specialties. There are some fantastic schemes around, primarily at Bangor and Brighton, and I personally feel (and it seems Taj did too) that these are a great way to reduce fatigue, regain passion in the field, and increase retention of our EM trainees.
We often see dying patients, or those approaching the end of their life, in the emergency department. It can be frustrating for us sometimes, knowing that with better planning, these people could have been cared for in their own home, comfortable and surrounded by family. They might have avoided the busy and noisy ED where often staff don’t have the time to ensure timely administration of palliative medications. Macmillan nurse John Sheridan gave a fantastic talk on how we can improve this, detailing work he’s involved with in the north east, such as dedicated palliative care ambulances, tools to identify these patients early, and schemes to support them at home to prevent ED attendances if possible. There’s a bit more on this over at the EMJ blog breaking down a paper on paramedics’ experiences of end-of-life care decision making.
Palliative care is living as well as possible for as long as possible. Looking forward to this talk by John Sheridan, caring for the dying is something we need to get right. #NEMC18
— Chris Gray (@cgraydoc) January 9, 2018
Chris Smith showed us a video of a successful pre-hospital thoracotomy (the recipient was in the room!) and outlined some of the advances in prehospital emergency medicine that made this possible. A great visual display and all credit to him for showing this on the big screen.
Geriatric emergency medicine is not only a big topic at the moment (recently I worked a shift where at one point we worked out the average age of patients in the department was 79!), but also could soon be a subspecialty in its own right, just like paediatric EM. Who knows, maybe in the future we might see specialist geriatric EDs… Charlotte Bates talked us through how we can identify elderly patients at risk through frailty assessment, comprehensive geriatric assessments, and other measures in order to try to prevent decline, and restore or retain independence. We’re probably very bad at this in the ED as clinicians and rely heavily on our therapy teams. We need to get better – this population is the mainstay of our work and we’ll all hopefully get old one day. She gave a comprehensive but wide ranging talk covering all things medical and trauma. Does your department have a geriatric EM lead? Do you know who they are? Have you read the TARN report on major trauma in elderly people?
My take home from @v_lottie re Geriatric EM: delirium may be temporary but frailty is progressive #NEMC18
— Kris Lawson (@lawson000) January 9, 2018
Just before lunch we had a run through three trainee presentations. Phil Dowson talked about how he made a change in his department surrounding shoulder reduction. They were sedating more than half of their patients and taking far longer than the 75% within 2 hours standard outlined in the RCEM clinical standards. Phil and colleagues introduced a ‘shoulder bench’ (handy video of how it works here) similar to the Oxford chair first described in the EMJ in 2011 by Chung et al, and managed to massively improve the experience for these patients, reduce the numbers needing sedation, and reduce time to reduction as well. Certainly something to consider in your own department. Graham McLelland has been trying to work out how we can separate stroke mimics from true strokes in the prehospital environment. FAST is quite sensitive but isn’t too specific and so a lot of patients get taken much further than their local hospital to go to a stroke centre. There are some scoring systems which have been developed such as the FABS score or the TeleStroke Mimic scores. Developing a good tool for prehospital care providers to use could help to ensure patients are taken to the most appropriate hospital. Finally, a topic familiar to those of us who regularly frequent Twitter – ketamine. Good usage and documentation is crucial when using drugs for conscious sedation. Catherine Chatfield-Ball audited this at a large London hospital, and found many ways that the overall process could be improved, such as decreasing vial size to reduce wastage, and changing the controlled drugs log book to more accurately record and monitor drug usage and disposal.
After lunch we were treated to some gory photos of police officers controlling catastrophic haemorrhage on modified pig carcasses, as firearms officer Sean Wheatley and ED consultant Richard Hardern talked about how police medics have been training to provide life- and limb-saving interventions as well as early first aid at the scene of an incident as a bridge to medical treatment by EMS. These guys are often first on scene, well before paramedics get there, and until recently haven’t been able to do more than basic first aid. Now tactical medics can apply tourniquets, chest seals, pelvic splints, and given prehospital analgesia whilst waiting for an ambulance to arrive. Great progress which can only improve things in the prehospital environment.
Kat Noble is a GP with specialist interest in emergency medicine and also associate medical director with the North West Ambulance Service, and she has been doing fantastic work to try to improve the way emergency departments stream patients to general practitioners. Main messages from this were to try to work out exactly what you want the GPs to do in your department as this will enable you to get the right GPs, and to use them effectively.
This is really good by @katfrasernoble
How best to use GPs in your ED? Partnership and communication key#NEMC18
— Alan Grayson (@dralangrayson) January 9, 2018
A lot of departments nowadays have a good-sized cohort of nurse practitioners, but there are still grumblings that they are taking away experience and skills from junior doctors, and some echoes of resentment towards them. Personally I feel that in the department I work in, our ENPs and ANPs do a fantastic job and complement our doctors well. They have so much skill, knowledge and experience that both doctors and more junior nurses can learn from. They’re not there to compete with us, they’re part of our whole team. It was refreshing to hear from Cheryl Moss who works in James Cook University Hospital that she and her colleagues are getting great support from their team and making a difference in their ED.
Taking a trip down memory lane to how we first attempted CPR (think bellows, sheets, and hanging upside-down from trees), Lewis Gray (a doctor from the darkside of anaesthesia and intensive care) gave a very amusing talk on how the ALS algorithm has gone from nonsense, to a structured approach, and now back to actually re-examining that approach to see if it’s really worth it (think adrenaline/amiodarone in cardiac arrest). Top tips from his talk include:
- Pre-charging the defibrillator before pulse checks
- Use of ECHO on the non-shockable side of the algorithm to ensure your compressions are effective and you’re not trying to compress an empty heart, also to look for reversible causes
- Think in parallel – what else can you add alongside ALS?
- Look to the future for adrenaline use (or not), defibs on drones, ECMO-CPR
- Education saves lives
Lewis Gray ‘Best ALS outcomes worldwide are in Stavanger, Norway and Seattle, USA, where BLS taught in schools’ #NEMC18
— NEM Conference (@NEMConference) January 9, 2018
Again a huge plug for the GoodSAM app – if you can do basic life support you should be on here so get involved at goodsamapp.org.
A great talk came next from James McFetrich on his own experiences with work stress and burnout. Fantastic slides and a great story to boot. He gave some key tips to try to manage your own stress at work, in order to avoid burnout. It’s crucial to talk to people about how you’re feeling, to find other things to do outside of work, and balance your physical, emotional and spiritual needs. On the topic of burnout, our own Liz Crowe and Iain Beardsell have produced a great podcast, which is fantastic listening and really builds on James’ messages from his talk.
In May 2017, there was a bombing in Manchester, affecting a lot of my colleagues here in Virchester who were either on call at the time, or came in from home to assist. Our own Alan Grayson gave an account of the response to this that was both brilliant and harrowing at the same time. The amount of respect I have for my colleagues and friends on that night shift is immense and I can’t begin to imagine what they went through. I certainly hope it doesn’t happen again. Some fantastic insight into how our response to major incidents is planned and maybe how it needs to change.
Make sure you know your major incident plan, where you fit in, and what your role would be if one were to happen, next time you’re on shift, at 3am. Simon has written a blog post also on the experiences gained and lessons learned from the Manchester attack. It has a lot of great tips, but only useful if you actually enact these things before it happens, so have a read and work out how you can improve your plans. When it does happen, there are people who will support you, friends and colleagues. It’s ok to talk.
And that concludes a great conference from the north. I’m looking forward to the next one. There’s also a northern paediatric EM conference in July 2018 to think about, and you can get updates on this here.
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