Authors: Nikki Abela, Dave McCreary, Becky Maxwell, Simon Laing, Andy Neill / Codes: CC6 / Published: 27/03/2015
Day 3 at the First Annual CPD Event Since the College Went Royal
Day 3 at #RCEMBelfast continued on yesterdays medical thread, with an excellent talk on Heart Failure by consultant Cardiologist Mark Petrie.
Here are some of his top tips:
- NICE recommend that you can use BNP to rule out heart failure in patients with SOB. – This has already sparked some twitter debate join in here
- If the ECG is normal, HF is unlikely.
- -blockers are good for CHRONIC HF
These, on the other hand, are things he advises you do not do:
- Use -blockers for ACUTE heart failure
- Give fluids
- Forget that 25% of patients are young and may present differently with orthopnoea and abdominal pain
Continuing on a cardiology theme, Francis Morris gave another hugely entertaining talk on ECG Tips from the Shop Floor (or Pitstop- which is where you will find him).
(why isnt this man on twitter again? #getfrancismorrisontotwitter)
Here are some of his take-home messages:
- P waves in lead I should not be inverted (causes are rare, so its usually a misplaced lead)
- Always read what is written on the automated strip
- Use the calculations of PR, QRS and QTc
- RBBB is rarely pathological, but RV dysplasia is the exception to prove the rule
- Low voltage criteria + tachycardia – think pericardial effusion
- LVH + “Dagger-like” Qs = HCM
- In WPW, RBBB pattern gives appearance of acute MI
- T wave inversion across chest leads – suggestive of PE
- If Ts also inverted inferiorly = highly suggestive of PE.
- Rule of thumb for QTc: If T wave ends beyond half of RR interval QTc is likely prolonged
Vince McGovern spoke then to us about COPD, advocating the GOLD guidance for this condition.
Frequent fliers are spiraling downwards with their condition, he pointed out, and in the ED we need to continue advocating smoking cessation. Think about antibiotic prophylaxis, take sputum samples (as pseudomonas is bad news and needs long courses of ciprofloxacin), he said.
When treating these patients, he continued, eosinophilia may have a role in predicting which patients do well on oral steroids.
ALWAYS ask about blood in sputum. CXR is only 90% re-assuring that they dont have serious pathology so refer for further investigation, he also highlighted.
Another interesting talk at the conference was given by nephrologist Niall Leonard on AKI, where he described the kidney like a smoke alarm- when it goes off its rarely because of a problem in the kidney itself – it is usually due to a problem in the body.
According to NCEPOD, management of AKI is suboptimal in 50% of cases, and in response to this Dr. Leonard has come up with an ABCDE approach for the management of kidney injury, which went down a treat with us emergency physicians (dont we all just love ABCDE algorithms?):
Next up was Gavin Lloyd who talked about improving ED care. This was a great talk about what matters to patients visiting our department, and how we can help improve their experience.
The senior meet and greet (RAT/Pitstop) was again praised as improving care. Interestingly the hospital in Exeter where he works is looking to recruit (paid) medical students to help with tasks like taking bloods and making teas for patients in the ED. He has recorded a separate podcast with Simon Laing which should be available on the website soon.
One of our favourite talks of the day came next (not that were biased of course), when our very own Simon Laing stood up and made us proud when he talked about #FOAMed. Now, we appreciate that if you are reading this blog, it is likely that we are writing to the converted, but we can assure you that as progressive as Emergency Medicine and the Royal College has been on #FOAMed, there were still many participants who felt enlightened after his talk. Of course, if you want to get involved with RCEMs FOAMed Networks work, please do not hesitate to get in touch.
After lunch came another of our favourite talks, not only because Rebecca Maxwell is one of our own, but also because she has done a fair bit of research on toxicology, and while we can be a bit blaze about Paracetamol Overdose, she did have some important messages for us, namely:
- Time and type of OD are crucial to management, where we should be aiming to treat single acute ODs within 8 hrs for maximum benefit and staggered ODs within 1 hr of arrival in ED
- Interestingly, the new guidance on paracetamol ODs cost 17.4 million per life saved
- Pregnant women have different weight calculations, where we should calculate the paracetamol dose taken on pre-pregnancy weight, and the NAC therapy dose on actual weight
- The future in this field is finding a way to predict who is going to get paracetamol toxicity and a lot of work is being done in Edinburgh on biomarkers
And as all good things come in threes, the #FOAMed crowd had a third avid supporter speaking at the conference- the excellent John Hinds. Speaking about airway management in the ED, John gave practical advice on his approach to RSI, and how it doesnt change regardless of location (and hes tubed people in a few locations!).
We were reminded here of the importance of an RSI checklist (everytime) and that, while the standard answer for the choice of anaesthetic agent is the one with which you are most familiar, that this isnt the case in resus patients if youre most familiar with using propofol in well, elective patients, for example. His drugs of choice are ketamine and rocuronium, and he discussed this further with us in a podcast interview, along with his scalpel, finger, bougie, tube technique for a surgical airway
The following topic was on difficult conversations in the ED, not only with patients but also with members of staff, where Sean McGovern advocated a SPIKES methodology approach to the two. For those who havent come across it or need some revising, here it is:
- Setting up the interview
- Perception assessment
- Invitation for information
- Knowledge sharing
- Strategy to go forward
Lastly, Charlie Martin spoke about how we judge success and promote safer practice in the ED. Key ingredients to safe ED services were based on a little TLC (no, not tender, loving care): Teamwork, Leadership and Culture. If you would like to read more on this topic, the RCEM published recommendations following a lot of (largely ongoing) work in this area.
And as all good things come to an end, sadly so did the conference. It was been thoroughly enjoyable for us to be there and to be able to share all this with you. The organizing team for #RCEMBelfast were absolutely brilliant and we, as a team have learnt a lot from each other through working together.
We hope our daily summaries have been beneficial for you and we hope many of you can make it to #RCEMManchester in September.