From SMACC Gold 2014 – here is Cliff Reid breaking down some resuscitation myths and dogma:
From SMACC Gold 2014 – here is Cliff Reid breaking down some resuscitation myths and dogma:
Auckland ED is currently conducting usability testing of the Storz C-MAC video laryngoscope. Resources are found below:<p><a href=”http://vimeo.com/40230198″>Introduction to the Storz/C-MAC Video Laryngoscope</a> from <a href=”http://vimeo.com/pemcincinnati”>Brad Sobolewski</a> on <a href=”https://vimeo.com”>Vimeo</a>.</p>
Literature regarding C-MAC use in ED
When patients fit into one of these categories and the patient is unwilling to accept treatment, we must decide whether to treat the patient against their wishes, which may require physical or chemical restraint.
In New Zealand we have a range of legislation relevant to these situations. Emergency Department staff need to be familiar with these pieces of legislation, as legal counsel is not always available within a suitable timeframe.
TREATING PATIENTS WHO ARE INCOMPETENT DUE TO ORGANIC ILLNESS OR INJURY
An example of this would be a patient who is intoxicated, has signs of life-threatening injury, and is combative and uncooperative. Restraint and sedation in this setting is covered under two legal mechanisms:
‘Common Law’ refers to legal principles that have been established through prior legal cases. It relies heavily on the concept of ‘legal precedents’, with NZ common law originating from English Common Law. Common Law precedents have established that doctors have a ‘duty of care’ to their patients that includes acting in the patients best interests if the patient is not competent to consent to or refuse treatment.
This principle is formalized in NZ legislation under HDC legislation, specifically The HDC Code of Health and Disability Commissioner Services Consumers’ Rights Regulation 1996.
‘Right 7’ of The Code states:
3) Where a consumer has diminished competence, that consumer retains the right to make informed choices and give informed consent, to the extent appropriate to his or her level of competence.
4) Where a consumer is not competent to make an informed choice and give informed consent, and no person entitled to consent on behalf of the consumer is available, the provider may provide services where –
a) It is in the best interests of the consumer; and
b) Reasonable steps have been taken to ascertain the views of the consumer; and
c) Either, –
i. If the consumer’s views have been ascertained, and having regard to those views, the provider believes, on reasonable grounds, that the provision of the services is consistent with the informed choice the consumer would make if he or she were competent; or
ii. If the consumer’s views have not been ascertained, the provider takes into account the views of other suitable persons who are interested in the welfare of the consumer and available to advise the provider.
PATIENTS WITH MENTAL HEALTH DISORDERS
These patients come under the Mental Health (Compulsory Assessment and Treatment) Act 1992. This act allows the provision of compulsory mental health treatment to patients who meet certain criteria, but does NOT allow the provision of other medical treatment. Treatment for toxicological aspects of an intentional self-poisoning, for example, would be covered under Common Law and the HDC Code as above.
For patients in the acute setting who are felt to be unwell enough to need care under the Mental Health Act, the relevant process is as follows –
Powers of medical practitioner when urgent examination required:
1) Subsection (2) applies to a medical practitioner who—
(a) conducts a medical examination of a person who is acting in a manner that
could give rise to a reasonable belief that he or she may be mentally disordered; and
(b) concludes that—
(i) there are reasonable grounds for believing that the person may be mentally disordered”
The relevant elements are a medical examination and a ‘reasonable’ belief that the patient is mentally disordered. The definition and relevant criteria for ‘mental disorder’ are as follows –
Mental disorder, in relation to any person, means an abnormal state of mind (whether of a continuous or an intermittent nature), characterised by delusions, or by disorders of mood or perception or volition or cognition, of such a degree that it— (a) poses a serious danger to the health or safety of that person or of others
An additional legal mechanism applies when patients present to the emergency department following an apparent suicide attempt. Section 179 of the New Zealand Crimes Act 1961 states –
Aiding and abetting suicide
Every one is liable to imprisonment for a term not exceeding 14 years who—
(a) incites, counsels, or procures any person to commit suicide, if that person commits or attempts to commit suicide in consequence thereof; or
(b) aids or abets any person in the commission of suicide.
The relevance of this for acute care providers is that aiding/abetting suicide includes inactivity, and failing to prevent suicide. This provides a clear legal requirement to treat the patient, even if they are refusing such treatment.
Deciding whether a patient is competent to refuse treatment, or requires restraint, sedation, or detention for the provision of care is a complex and potentially risky process, and should involve the most senior ED doctor available.
Scott Orman, ED Specialist, and Jacob Munro, Orthopaedic Surgeon
The x-ray above shows what could be interpreted as a relatively innocuous injury – an apparent isolated undisplaced fracture of the posterior malleolus of the ankle.
Suitable for conservative management, discharge from ED, and follow-up in fracture clinic?
The posterior malleolus is typically fractured by rotational injury an/or axial loading. Posterior malleolar fracture WITHOUT other injuries to the ankle or lower leg is uncommon – only 4% in one case series examining all ankle fractures. More commonly, posterior malleolar fractures occur in combination with proximal fibular fractures (Maison-Neuve), syndesmosis injury, posterior tibiofibular ligament injury, and/or spiral tibial diaphyseal fracture. These injuries commonly require surgical intervention, and the presence of a posterior malleolus fracture with them worsens prognosis.
Even if another injury is NOT present with a posterior malleolar fracture, criteria for surgical intervention are complex and highly surgeon-dependent.
THE BOTTOM LINE
Upon discovery of a posterior malleolar fracture in the ED – maintain a high index of suspicion for associated injuries. There is a high chance that other structures are injured also and that surgical intervention is required for an unstable ankle. Careful clinical examination is required, (including the proximal lower leg), and the threshold for further imaging (especially CT) should be low.
In accordance with this, the orthopaedic department at Auckland Hospital have requested that we refer all posterior malleolus fractures to them acutely for review, even if no associated injuries are immediately apparent.
Diagnosis of an isolated posterior malleolar fracture in a young female military cadet: Int J Sports Phys Ther. 2012 Apr 7(2): 167-172
Posterior malleolus fracture: J Am Acad Orthop 2013 Jan 21(1) 32-40
From the AED departmental CME program – James Le Fevre’s slide set on ‘killer ECGs’…
Resources for ultrasound guided LP:
Not quite! Rather, Crisis Resource Management (CRM) is a complementary approach to Simulation Based Training (SBT). It can enhance current ongoing medical simulations or provide foundation for a vigorous curriculum when launching new simulation programs.
Crisis Resource Management is the ability to translate medical knowledge to real world actions, in the setting of an emergency.
Rather than a separate entity from medical simulation, CRM principles can be looked at as a way to focus and shape medical simulation curriculum and especially the objectives of each case to focus upon development of critical skill-sets that contribute to optimal team function and success during crisis.”
Read the rest HERE…
Recently I had the pleasure of attending a superb AWLS course in Queenstown. The course was run by a group of intrepid clinicians who decided several years ago to import AWLS from the United States. You can read about the group (and more importantly, book a place on the course!) here:
Wilderness medicine is in may ways the ultimate in prehospital care – it involves providing care to patients in an frequently austere environment with often very limited personnel, equipment, and communications. For emergency department doctors like myself, it also separates us from the security of readily accessible diagnostic investigations.
At its core wilderness medicine represents the same pathologies as emergency medicine, although environmental issues are obviously more common than in our urban ED and regional HEMS (check out this article about some recent lightning strike patients treated in Waikato ED!). The challenges encountered by treating clinicians however are very different, and solutions rely on communication, improvisation, adaptation, clinical judgement, and common sense… plus (of course!) duct tape and a pocket knife.
The course itself included a variety of teaching formats including interactive lectures, group discussions, practical skill stations, and in-situ simulation. The organizers successfully arranged significant rainfall on one of the simulation afternoons – ever tried running a trauma resuscitation in the rain under a tarpaulin? (Credit is also due here to some of the local medical students, who were quite willing to become hypothermic for the sake of medical education)
Without giving away too much of the detail on the course, here are some examples of the material covered:
Single rescuer rolling a trauma patient with cervical spine control:
AED will shortly be transitioning from the venerable Oxylog 2000 to the Oxylog 3000 plus.
The video below is a superb introduction to the Oxylog 3000 series, covering anatomy, settings, and connections:
The Oxylog 3000 plus has some additional features, including embedded capnography and a feature called Autoflow – you can read the official Draegar infomation about Autoflow HERE, or you can read the Sydney HEMS take on it HERE – ‘PRVC isn’t a country in Sout East Asia’.
Prior to testing your newfound knowledge on real live patients, you can have a go at the Draegar Oxylog Simulator by clicking HERE. (This page takes a while to load, select ‘manual simulation‘ from the ‘simulation‘ menu once the page has loaded)
George Douros (Emergency Physician from the Austin Hospital in Melbourne, ) has created these charts to help you ‘own the Oxylog 3000’ (sourced from the superb lifeinthefastlane.com) – click the images to enlarge:
By Dr Owen Doran – FACEM, AED lead for ultrasound
Credentialing for bedside ultrasound is essential for the safe and trusted use of ultrasound by Emergency doctors. The ACEM provides guidance for credentialing a practitioner to become an Emergency Medicine Sonologist, and policies can be found on the college website:
This involves attending a course and performing a minimum number of proctored, documented and acceptable exams in that module, of which at least 50% are indicated and 5 are positive for pathology.
You also have to pass an ‘exit exam’ per ACEM & ASUM guidelines, which consists of performing a focused scan on a patient/volunteer while observed by an examiner (radiologist, ultrasonographer or previously accredited EM sonologist).
Each individual department is responsible for adopting and implementing this process.
In practical terms, this usually means a member of the specialist team is identified as the ultrasound champion for the department, and they help to coordinate this process.
Scans can be reviewed realtime, with direct supervision, or more commonly with a review of images. To have reviewed images accepted, they have to be of good quality, with labelling and patient information complete, and a confirmatory imaging or treatment modality must be available. This can be departmental ultrasound, CT or operative findings. The fact that a patient went home and did not come to further harm is not enough.
The easiest way is to keep a log of your scans- I have given an example of this below. This can be done as paper copy, or computer file. I have given an example of a file that might be compiled for review of a FAST scan below:
FAST images and correlating CT report:
Associate Professor in Emergency Medicine Richard Paoloni, from Concord Hospital in Sydney, reviews topics in EM over the last year, including high-sensitvity troponin, non-invasive real-time vital sign measurement, and new forms of anticoagulants.
Link for accompanying audio is below the slide set
Click HERE for the audio (right click and open this in a new tab)
(by Mike Nicholls)
You are in ED when an R40 is received that a young victim of road trauma is enroute. She is hypoxaemic, tachycardic, hypotensive, and combative, and has facial, chest and limb injuries including a mangled upper limb and femoral shaft fracture.
ETA is 5 minutes.
Oh dear. What to do…
Try using the highest fidelity simulator available to you (your imagination) to plan what you might do to prepare for the arrival of this very unwell patient.
In particular, which procedures might be needed? (hint, below is a list of procedures, with internet links, which you may wish to be familiar with PRIOR to her arrival…Another good source of info for procedures is the text book by Roberts and Hedges. We have a copy at staff base, but I believe if you are on the training program this book is subsidized, so is essentially FREE to you. Get a copy from Medical Books, just down the road from AED.)
Be positive! Good luck!
Please note, we probably won’t cover all of these procedures on 30 July.
CRICOTHYROTOMY (thanks to Petro)
RAPID RHINO INSERTION
CHEST DRAIN INSERTION (thanks to Mark Gardener)
CHEST DECOMPRESSION AND DRAIN INSERTION – click HERE for many links – LifeInTheFastLane: Own The Chest Tube!
LIMB TOURNIQUET APPLICATION
(suggest watching from the 10 minute mark for landmarks)
PELVIC SLING APPLICATION
DONWAY FEMORAL SPLINT APPLICATION
(Somewhat weird Smurfs-in-snow version, takes 3 minutes. In the ED we would advocate removing ski boots prior to application…)
E-FAST ULTRASOUND EXAM
(Some good views demonstrated, although I don’t agree with their comments about not visualising the kidney in the perisplenic view)
ARTERIAL LINE INSERTION
(check this out from 2.10 until 4.40)
CENTRAL LINE INSERTION
(Not really applicable in trauma, but still…Also, I think we would generally leave a catheter in situ)
USE OF A STAPLER – click HERE
SUPRAPUBIC CATHETER INSERTION – click HERE
(We would use ultrasound to aid this procedure (ie ensure that really is a large urine filled cavity))
ED THORACOTOMY – click on this link for a ‘how-to-do-it’ pdf: Emerg Med J-2005-Wise-22-4
PERI-MORTEM C-SECTION – click HERE
From SMACC 2013 – Anthony Holley (Intensivist from Royal Brisbane & Women’s Hospital, LCDR in Royal Australian Naval Reserve) brings a military perspective to advances made in trauma management on and off the battlefield.
Click HERE for the audio, accompanying slides below:
From the SMACC 2013 conference – Scott Weingart discusses intubating the shocked patient. Hypotension, titration of induction agents, planning ahead, and an interesting new metaphor to describe propofol…
Click HERE for audio (right click to open it in a new tab), accompanying slides are below. Enjoy!
From our colleagues across the Tasman at The Sonocave, HERE is a video tutorial about the RUQ view of the FAST scan. It covers image acquisition, exploration of the entirety of Morrison’s pouch, and interpretation of image findings. note the audio is quiet, so crank the volume up…
With the use of high quality simulation, in a safe learning environment, we aim to:
Click HERE for the simulation timetable
From the 2013 SMACC conference – this is Cliff Reid delivering a talk called ‘Making Things Happen’:
Using trauma as an example, Cliff looks at and provides his solutions for elements of resuscitation that can derail even the most competent team – including cognitive overload, inappropriate team tasking, loss of situational awareness, and the inability to MAKE THINGS HAPPEN…
This talk is a great companion to ‘Own The Resus‘
As part of your AED orientation and departmental CME we will be running through basic airway survival skills on Tuesday the 10th December from 2pm to 4pm.
We will be covering
I have attached some links for pre-reading around the ED airway, RSI and checklists as below:
– This is a collection of airway based podcasts and resources from Scott Weingart on his EMCRIT blog, presented all on one page and is an invaluable resource. Goes into a little more detail than we will on Tuesday, but the rest we will be covering on another airway session.
– UK Site, based on the outcomes from the NAP4 study. Good, one page RSI checklist developed by anaesthetic regs in the UK and a nice presentation of the rationale behind safer intubation using a pre-intubation checklist.
– By Cliff Reid (of the resus.me blog). This is an awesome video demonstrating a concise run-through an RSI checklist. Useful for a brush-up on paeds RSI.
– Just for a bit of fun! If NSW HEMS can do it safely on the side of a cliff it can be done safely anywhere!
From Dr Fen Moy – drug information sheets. This will be covered in a second session later in the run
Click HERE for the file
If only patients came with labels…
If you have your Auckland Trainee Airway and Procedural Skills logbook – please bring it along with you on the day! Cheers – Alana