PODCASTS WORTH A LISTEN - CPD ON THE MOVE!

Some of you have been asking me this week about which educational podcasts I listen to, so I thought I would put up a quick post with some of the details and links.

Podcasts can be a great way to keep up to date. You can select topic specific podcasts, or choose to listen to monthly updates covering the latest in evidence based medicine. The world really is your oyster. CPD on the move!

First up is http://theresusroom.co.uk/

The Resus Room website states the following:

At its heart TheResusRoom is a podcast based site which can either be accessed by the webpage or via iTunes here. At least twice a month we will bring you podcasts on a variety of Emergency Medicine topics that you’ll use every day in and around the resus room, centered around evidenced based medicine and with reference to national and international guidelines. In addition we are now moving towards multidisciplinary authors and topics with our blog. This will cover PHEM, EM, ITU, Anaesthesia and Acute Care topics via a small group of superb authors.

This week I've listened to the Trauma care 2018 podcast - a great update, including use of TXA and NICE Trauma Guidance.

Next: https://dontforgetthebubbles.com/svt-in-infants-at-dftb17/

Don't forget the bubbles is a fantastic site discussing all things paediatric. This is not just ED focused, but most of the site and podcasts are highly relevant to those working in the ED

The link above is to a talk I've listened to this week discussing SVT in paeds - great learning!

The RCEM Learning site also has great podcasts, as well as other eLearning resources. For those of you new to the ED, there is a fantastic set of induction resources

https://www.rcemlearning.co.uk/foamed-layout/

My last top tip for great podcasts is the St. Emlyn's gang from Manchester. 

http://www.stemlynspodcast.org/

I've recently listened to the St. Emlyn's podcast on Debriefing in Critical Care - highly recommended.

Hope this little list helps. Let me know if you listen to something great, and if you do make sure you share your learning with your colleagues!

Sarah  

 

Exciting Opportunity in Worthing ED

Exciting Opportunity in Worthing ED

Really excited to tell you about an opportunity to apply for a clinical fellow role in our Emergency Department with a specialist interest in Point of Care Emergency Ultrasound. This role has been developed by our current (and 1st) fantastic ultrasound fellow, who has worked with our resident Ultrasound guru, Dr. Shaun Pitt, to develop his clinical point of care ultrasound skills. Over the last 4 months our fellow has developed a log book of clinical experience and is now ready to be signed off as USS Level 1 competent; a great tick on his CV for upcoming ACCS applications. 

We are now have the opportunity to offer this role to another motivated doctor(s) who would like to join our team, experience working in an ED that, although challenged by 'winter pressures' ,continues to function well and does not suffer to the same degree the significant exit block experienced by many other trusts. We are proud of the team we have at Worthing, embrace and value our flat hierarchy, and strive to make all our posts as enjoyable and educationally valuable as possible. In fact, during a recent clinical supervision meeting with one of my trainees, I was told that he had loved his placement and really looked forward to coming to work; quite an accolade given he has been working in the department during one of the NHS's most challenging periods on record.

This role would suit someone in their first year post foundation training or someone with significantly more experience; we can tailor to the individual and are keen to talk with anyone who might be interested in applying. And if this isn't the role for you now, but you know someone who might be interested, please share!

Quick on the link below to read the job Description and apply. Closing date 15th April. 

Click here for JD and to apply

Please contact myself , Shaun Pitt, or Jon Burton to discuss further or arrange to visit the department. 

sarah.hall@wsht.nhs.uk

jonathan.burton@wsht.nhs.uk

shaun.pitt@wsht.nhs.uk

 

Lessons for Worthing from the Western cape.

I have never been to a conference before, they didn’t particularly appeal to me despite being an unashamed ED nerd. I don’t find a lecture a fantastic way to learn and I turn my nose up at networking. Which is why it seemed strange decision to fly halfway round the world on my own to go to a field with 150 people I have never met to talk about emergency medicine in Africa. This turned out to be the best educational decision I have ever made. I want to thank Sarah Hall (a bona fide supermentor) right from the get go for encouraging and helping me apply to the Worthing educationally body, who helped fund this unparalleled experience.

To explain a bit about the festival for those who just thought I was off on a jolly to South Africa (he says as he looks over a view of table mountain). It was set up by a group of enthusiastic Emergency doctors based in cape town- they produce free online resources under the tittle “brave African discussion in Emergency medicine”- BADEM (not dissimilar to our em-wsht.org). They decided to get a group of people passionate about this topic together. But the simple genius was to do this in a beautiful location in the mountains 90 minutes out of town. Talks were in a Bedouin tent , questions were around a campfire, wilderness simulation was in the actual wilderness, the ultrasound machines were convenient close to the bar (I didn’t think I would be able to combine love of whisky and scanning) and we slept in the poshest tent I could imagine.

What made this experience so special is the equality and community this set up established. I learnt from people of different grades, professions and nationalities and all hours of the day and night. We learnt together, swam together and drunk together. I asked a criminologist about causes of drug epidemics over lunch, a Lithuanian EM registrar the technical details of filming resus cases over dinner and a paeds EM consultant about kindness around a campfire. Most importantly I felt I belonged. These are my people, I am not quite sure who we are but I know what we do. We try and make things better for acutely unwell people and we love doing it. It doesn’t matter if I am in Worthing or Western cape. These are my people and this is what we do.

But this is all very well and good, I was once a cynic like some of you reading this, what’s the point of the airy-fairy nonsense. Well here is some lessons, entirely of the top of my head,  that I think can we heli-evac straight into our lovely little district general hospital.

 

1/ Specialty bashing. Stop. I have been guilty of this. It is fun to laugh at an orthopod and convenient to blame a GP. It makes us feel better about ourselves. But it makes them live up to their stereotypes and leads to tribalism and bad communication which harms patients. We are all on the same team.

2/ Pregnant women can get scans. The risk exists to the foetus, but is a lot less than you think. Like all other radiology decisions, we should think twice, but if they need it, they need it.

3/To CPR or not CPR- this was nicely phrased as the chain of survival- if they can survive they chain they should have CPR, if they can’t they shouldn’t.

4/ Artificial Intelligence is coming, we need to get on board or fall off the train. If by 2025 if computers can’t read ecg’s better than me I’ll eat my hat. (setting the bar low…). In the short term there are much better ways to refer than by fax.

5/ ECG’s (til the machines take over)- check the p wave rate to help with distinguishing type of heart block.

6/ You pretty much can’t overdose on Anti-retroviral drugs.

7/ But you definitely can on anti TB meds.

8/ Feeling rubbish after a major incident for a few days is normal, psychiatrist early don’t help, friends do.

9/ Be kind.

10/ Super mentors make you jobs worth doing. They keep us going. The South African’s seemed pretty lucky to have at least a few. I am luckier in Worthing as I have a whole squad of them.

 

This list is completely off the cuff, I am writing this without internet and without the programme of talks in front of me. I will go back and re post this with credit to those who taught me the above when I am a bit more linked in to the grid. But I needed to share my sheer enthusiasm with my fantastic colleges back home who are valiantly holding the fort. After all this inspiring learning I am genuinely looking forward to coming and joining them on the shop floor once again, well, right after a quick holiday- I’m in a very beautiful country after all.

                                                                                                                                        

Ultrasound Machine Audit

It's my turn to hijack the blog now, mainly because I couldn't work out a better location to post my recent work. However don't be disarmed, this is still very much ultrasound based. Whilst bed-bound with a bout of tonsilitis I decided to audit the use of POCUS in WSHT, with a focus on how well we document our findings - it's dry, but try and enjoy... (if you make it to the end there's a treat)

 

Ultrasound Audit in Worthing Hospital Emergency Department

T. Muth, February 2018

 

Aim:

To assess if the use of the department ultrasound is in accordance with the Royal College of Radiologists’ Standards of Provision (1)

 

Methods:

Data from the months of December 2017 and February 2018 were used to analyse all saved images to ensure that their records are compliant with the guidance stated above. The raw files from the ultrasound hard drive were then associated with the patients’ respective clinical notes from the emergency department, using computerised medical records

 

Background:

The POCUS movement has exploded recently with the easy education and data sharing spread by online methods. However, fundamentally it is easy and fast to use with minimal risk to the patient. It has helped reduce time to diagnosis and aid in bedside procedures such as difficult vascular access. However for the pictures to be transferred to the hospital-wide image software from ED and be trusted in ongoing care the images need to be reliably documented and saved. Along with this the user needs to be aware of their limitations and keep their skills up to date.

The Examination-specific standards dictate that:

·         The department should have written guidelines for the range of ultrasound examinations undertaken

·         All ultrasounds should be justified

·         A range of images should be saved to PACS to provide a records of the examination for case review and audit purposes

They further state that each scan report should include:

·         Patient’s ID

·         Date of scan and report

·         Clinical information and indication for scan

·         Name of examination performed

·         Name of scanner

·         Description of findings

·         Limitations encountered

·         Comparison of previous relevant imaging

·         Conclusion – answer to the question asked when performing the scan

·         Documentation of communication with referrer when findings are important or unexpected

These guidelines form the basis of this quality improvement project, hopefully highlighting where documentation and file management can be improved within the emergency department

 

Results:

70 scans were saved to the ultrasound machine hard drive within the dates of 20th December 2017 and February 20th 2018. 15 of these files were excluded from the audit as they had no images/videos attached, allowing 55 files to be analysed. 11 files include videos only whilst 29 contained photos only. 29 files contained both videos and images

Patient’s ID

A total of 45 patients (82%) had some form of identification- 16 had at least their MRN number and 29 had name only. 10 had no identifiable information

Date and time of scan

All files automatically had date and time logged on the computer

Indication for scan

25 out of 55 scans did not have a documented indication on the report. The most common indication was ‘Flank Pain’ with 6 documented, closely followed by abdo pain, 5, and chest pain, 4. Accordingly 15 of these scans were abdominal scans, excluding 6 aorta scans, 1 fast scan, 2 IVC scans and 2 gall-bladder scans (on image interpretation). 15 scans were echocardiograms, and the remainder were either unclear, bladder scans or pre-natal scans

Name of professional

7 users in total logged scans during the period used. 17 scans did not have a documented user

Description of findings

The majority of cases, 24, did not have documentation of the scan in the clerking notes. 21 cases were documented with findings. Due to lack of patient identifiable information it was not possible to locate the notes of 10 scans.

Comparison with relevant imaging

Of the 21 scans that had documented findings, only 6 were not verified by further imaging and investigations. A total of 14 scans were verified to have the correct findings on POCUS by further imaging, including ultrasound and CT. There was 1 incorrect finding (documented as ‘hydronephrosis present’ which was excluded by CT)

 

Conclusion:

The majority of documentation was well done. However, of the 55 patient images analysed, only 21 were documented in the patient notes which is under half of all cases. Reassuringly nearly all of these documented cases were deemed correct by definitive investigation, supporting the use of POCUS as a helpful tool in the ED for speeding up diagnosis

 

Next Steps:

The aim for the future is to have images from the ultrasound machine uploaded to the trust PACS system. In order for this to occur, documentation needs to be accurate to ensure correct files are allocated to the correct patient. Accordingly, this audit will hopefully act as education for staff about current guidelines for POCUS in the emergency department. Such a tool to improve the documentation would be to have a print out of the guidelines in simplified form on the ultrasound machine itself to act as a prompt when inputting data. A further audit will be carried out to ensure the implemented changes improve documentation

 

References:

1.       The Royal College of Radiologists, the Society and College of Radiographers. Standards for the provision of an ultrasound service. London: The Royal College of Radiologists, 2014. Ref No. BFCR(14)17.

 

Here's a couple of cool images picked up on my searches - try and guess what they're showing, answers below.

Picture 1: Aorta scan, enlarged with clear aneurysm

Picture 2: Sniff test showing the collapsing IVC

opportunistic teaching and sedation

Running through so cases today, it is nice to work in a department when this ad hoc teaching is encouraged.

Discussing sedation and the wonderful smacc podcast came up in conversation.

to listen or watch can go here

 

PSYCHIATRIC EMERGENCIES FOR THE ADULT PATIENT

Happy New Year all! 

A massive thank you to EVERY member of staff who has been working over the Christmas and New Year period. You are all amazing and have shown such dedicated commitment to the department and our patients over this extremely challenging period.

To kick off learning for 2018, please take a few minutes when you can to check this learning modules on the RCEM Learning website. It is intended to provide some guidance on commonly presenting psychiatric problems in the acute environment, focusing on the key elements of history in the context of making an initial assessment and provides some information on immediate management. 

https://www.rcemlearning.co.uk/modules/psychiatric-emergencies-for-the-adult-patient/

As I'm sure you are aware there have been some recent changes to the Section 136 of the Mental Health Act which will impact Emergency Departments. The link below takes you to useful college guidance relating to this.

 

That's all for now! Thanks

Sarah

The excellence around me

I am probably quite an average doctor. I am early on in my training, I rarely come up with a genius diagnosis no one else could have thought of. The times when I have saved a life are few and fair between.

However at Worthing I think i can deliver excellent care. This is because I am surrounded by excellent (in no order) juniors, seniors, receptionist, nurses, porters, Occupational therapists, HCA ect. ect. ect.) 

I feel we do not tell each other this enough. If we do we forget. It is human nature to forget praise and remember criticisms. 

Well now we can submit a greatix 

This fantastic idea has been started elsewhere and spread via social media ans #foam. When people ask if it is my idea I generally say I stole it, which is half true, you can't steal what is freely shared. Which is why I love FOAM.

After working out how to utilize this website to help do this I was going to wait until January to launch. Then I remember where I work. Whilst everyone else is winding down we are getting busier and busier. This is the time of year we most need to remind each other quite how regularly extraordinary we are. 

HEAT - DIAGNOSIS AND MANAGEMENT OF ?NEUTROPENIC SEPSIS IN THE ED

A short but really important post today to remind everyone of the importance of assessing for and promptly treating potential Neutropenic Sepsis in the emergency department.

There are 2 take home messages;

Firstly suspect neutropenia (Neutrophils <1.0) in any patient who

Has received IV or oral chemotherapy within the preceeding 4 weeks

Is a known haematology patient, within 100 days of autograft or 2 years of allograft

**MDS patients should be treated as neutropenic regardless of absolute neutrophil count

Secondly, if neutropenic sepsis is suspected, DON'T WAIT for blood results - start antibiotics immediately. You should suspect NS if if there are any positive SIRS criteria.

Full guidelines can be found on the Trust Intranet. The flowchart below is a useful guide. Click on the image below to see the full flowchart.

If you aren't sure what to do in any individual patient, ask a senior - don't delay.

A long shift leads to a short post

After a couple of long but educational shifts with my esteemed boss @lifeinedcom, and although we all love some fancy FOAM learning - the shop floor is where the real lessons are.  However this means less time for blog writing. 

But just enough time for a quick ultrasound update.

Last but not least we welcom fresh blood onto the physical shop floor and two new editors to the website. I expect lots of lovely ultrasound content from Shaun and Theo. 

I DO REMEMBER........

Following on from discussion at departmental induction yesterday, where we welcomed our new FY2 doctors, I was reminded today of this fabulous TED Talk discussing culture in medicine.

I you haven't already, do take a few minutes to watch, listen and reflect. Particularly poignant at the moment given recent publicity about the GMC investigation of  Bawa-Garba

An open and honest culture is essential for learning and patient safety.

NOTHING LIKE A BIT OF HEALTHY COMPETITION TO MOTIVATE.......

So, having had 'my' blog hijacked by Dan - Worthing E.D's first (and fabulous) Educational Clinical Fellow, I've thought I should get my a*** into gear and get on with some content myself! 

Firstly, I have to congratulate Dan on getting to grips with website editing; he has done this entirely himself, using the squarespace interface which this website is built on. My input was purely the mechanics of how to access the site; any advice I gave beyond that was probably more of a hinderance than help! Dan is setting up some great education in Worthing ED - if you work in the Trust, or are visiting some day make sure you get involved in some way.

This is the first of a series of blog posts I plan to write about my recent trip to San Francisco to attend "The Teaching Course". This was a pretty awesome 4 day event organised and run by The Teaching CO-OP, a group of clinicians from around the world who describe themselves as a community of dynamic thinkers who are passionately motivated to bring a relevant, engaging, and learner centered environment to the  world of medical education. 

The course proper was a 3 day event covering topics such as how to 'do' a presentation with the awesome Ross Fisher, (if you haven't listened to him speak or read any of his work, make sure you find time to do so), improvisation for medical educators, stress inoculation - specifically relating to simulation training, curriculum design, feedback and remediation. There were also sessions on wellbeing, dealing with difficult conversations (with a reminder that it is often the conflict between colleagues that causes more stress than difficult / bad news patient interactions) and the importance of emotional contagion (more on this in a future blog).

I also attended 2 pre-conference workshops; the first on social media and how it relates to modern medical education, and the second titled "The Learning Course", which explored the science of learning, how we can embrace these principles in our own learning, and as educators how we can use this knowledge to help our learners. 

So all in all, a fabulous 4 days of education, which I will share with you over the next few weeks via the blog. Hope to discuss some of this stuff with many of you face to face soon.

And by the way Dan - keep the content coming.....it's "our" blog!

Sarah      @lifeinedcom

Em-wsht phase 2...

I have hijack Sarah's blog for my first every blog post. Let's see how long she takes to notice. . .

  • How to sleep after night shifts
  • How to  control the conversation with a drunk person
  • How to persuade a 4 year old to open their mouth.
  • How to talk to a grumpy neurosurgeon. 

The list of "things they don't teach you in medical school that might come in hand as a doctor that you'll end up learning off a mate/teaching yourself" is a long one.

I can now add "editing a website" onto that list.

A splash of Sim guidance and a introduction to ultrasound is what I've added so far. I hope this continue to be more useful as we can expand it. Watch this space. 

Our department's "one minute read" has now migrated from physical posters in the virtual world as well. Although the good old-fashioned paper will still be there. 

Hopefully our physical FOAM wall will be up in the department too.

More detailed local guidelines also available and being continually expanded at drtoolbox (link on educational page of trust intranet)

Any suggestions, queries and general non specific enthusiasm welcome

Dan

Educational fellow 

@notdocdan

Hot Topic August 10th 2016

Kicked off Hot Topics teaching today with our new doctors. Discussed a case that came through the department last week, highlighting the management of ? Neutropenic Sepsis, and then discussed current general sepsis guidance, including reference to recent NICE Guidelines. 

Links to RCEM podcast and recent www.theresusroom.co.uk podcast on sepsis are available on the Hot Topics Sepsis page.

Lets begin....!

This is the first blog post of the newly created educational resource for Emergency Medicine at WSHT.