Blood gas workshop – SASSiT

This is the PDF of the Blood gas workshop run for the SASSiT workshop

Blood gas workshop SASSiT

Post by @QuirkyMD

Unlocking the mystery of the ABG

Part 1 – Acid Base

So this is a topic that I keep coming back to… I guess because it is something that is used pretty much every day in my clinical practice.

I found found some nice tips and memory aids along the way … am keen to share them

These are some cool examples that will take you through the 4 basic acid-base disorders

• respiratory alkalosis
• respiratory acidosis
• metabolic acidosis
• metabolic alkalosis

Examples: JoziEM ABG examples

When you take a deeper dive, you will see that there is a bit more to these examples than only the primary acid-base disorders. But this is a good place to start.

PDF of workshop: JoziEM ABG workshop

This is the updated version of my ABG acid-base cheat-sheet (which has evolved over the years).

This is the most amazing poster by Amy O’Donnel – I usually laminate a copy and put it close to my blood gas machine(s) at work.

 

References:

1. O’Donnel A. ABG as easy as 123  Accessed [9/11/2018]
2. 2. Joshua Steinberg. LITFL. Acid base worksheet
3. Camody JB, Norwood VF. Postgrad Med J 2012; 88 A clinical approach to paediatric acid base disorders

post by @QuirkyMD

 

 

#Finn’EM2018 Blood gas workshop

Blood gas Workshop – FinnEM2018

This is the blood gas workshop that goes through the following acid-base disturbances:

• respiratory alkalosis
• respiratory acidosis – acute and chronic
• metabolic acidosis – uraemia
• metabolic alkalosis

Download the blood gas examples: ABG Blood Gas workshop

This is the most amazing poster by Amy O’Donnell – I usually put it up next to the Blood Gas machines in my department.

Download ABG easy as 123 poster

This is my own reference card that I have compiled from a number of resources to help with Acid Base ABG disorders.

Please check out the bottom part of the hand-out for mixed disorders:

• delta gap
• delta ratio

Download Blood Gas Workshop Worksheet

Two fantastic resources that I have found for acid-base and blood gas examples to practice:

• derangedphysiology.com
• lifeinthefastlane.com

References

1. O’ Donnel A. ABG … Easy as … 123 Feb 2008. Avail at http://www.aci.health.nsw.gov.au/_data/assests/pdf_file/0004/2200675/ABG_poster_large.pdf Accessed [2/4/2015]
2. Joshua Steinberg. LITFL. Avail at http://lifeinthefastlane.com/wp-content/uploads/2010/04/ArterialBloodGas_Interpretation_ABG.jpg [Accessed 7/1/2018]
3. Camody JB, Norwood VF, 2012. A clinical approach to paediatric acid base disorders. Postgrad Med J 2012; 88A clinical approach to paediatric acid base disorders. Postgrad Med J 2012; 88
4. George YWH. Easy way to understand Stewart’s Acid Base

 

post by @QuirkyMD  #FinnEM2018

All about Tranexamic Acid

This blog-post is intended to provide the information required for the ALS practitioner to complete their theory component for the 2018 CPG update with regard to TXA. To access CPD points for this activity (blog post) please see the information box at the bottom.

This resource may also be used to inform any interested party in the physiology, pharmacology and use of Tranexamic Acid in the emergency setting.

Some definitions before we start

First of all – Let talk about clotting

The coagulation cascade is something we need to have a basic understanding of if we are to understand where TXA works, and how it works.

The focus of the information presented here will be around the trauma patient, but the information presented can be extrapolated to any patient with major bleeding, and activation of the clotting and fibrinolysis cascade.

The first thing we need to understand, is that where there is bleeding (as a result of trauma, or damage to vessels, vessel rupture), there is clotting. Where there is clotting, there is an internal process of fibrinolysis (break down of clots). The body is continuously aiming to achieve an environment that is in homeostasis, or balance. When a clot is formed, it puts distal tissue at risk, and so it must be broken down eventually.

This is completely normal. Refer to diagram below and description that follows to understand the coagulation cascade a little better:

    http://derangedphysiology.com/files/Coagulation%20cascade.pdf

1: Resting Platelets

• Platelets can be thought of as sentries floating around the body, alerting the system if there is a problem noted.
  • Healthy cells in the vasculature produce the following chemicals which inhibit platelet aggregation
    • Nitrous Oxide (vasodilator)
    • Prostcyclin
  • Damaged cells make less of the chemicals above and so there is increased chance of clotting in vessels
• Platelets have receptors on them, that if activated, will increase the risk of clotting and platelet aggregation
  • ,These receptors are activated by the following:
    • Thrombin, thromboxanes and collagen (these are usually present when there has been some trauma to the endothelial lining of the vessel)

2: Platelet Adhesion

• When receptors are activated on the platelet, there are a whole lot of changes that occur
• The receptors on the platelets are activated by collagen exposure to the blood (it should be covered by the protective lining of endothelium)
• Platelets cover the collagen and release a whole load of chemical mediators

3: Platelet Activation

• Once the chemicals are released from platelets that have already stuck to collagen
  • Chemicals include:
    • ADP, thromboxane A2, serotonin, platelet activation factor and thrombin
  • The more platelets are added to the clot, the more the platelets release the chemicals above and the more platelets are added to the clot

Below is an image of the triggers to platelets, and the effects when the platelet receptors are activated.

4: Platelet Aggregation

• Mediators and Calcium are released, resulting in more platelets joining the clot, this activates more platelets, and results in the positive feedback mechanism that is the clotting cascade.

5: Clot formation

• Local stimulation of the clotting factors occurs and tissue factors are released.
• Thrombin joins the clot resulting in the conversion of fibrinogen to fibrin, this strengthens the clot
  • Fibrin is a tough fibrous material that bulks up the clot and weaves the red blood cells and platelets together more tightly to hold the clot together

 http://www.daviddarling.info/encyclopedia/F/fibrin.html

6: Clot Fibrinolysis

All clots will need to be broken down again with time, as soon as there is local activation of the clotting factor, there is also local fibrinolysis. This is a safety mechanism to prevent damage to the tissues distal to the injury in the vessel, and assists with healing.

This is helpful with small injuries to the vessels, however, in patients who have a systemic activation of clotting due to massive or severe trauma, the activation of systemic fibrinolysis can increase the threat to life.

Where there is massive clotting, there is massive fibrinolysis, and this is counter productive in the patient who is bleeding to death.

Plasmin

Plasmin is an enzyme that destroys the fibrin mesh, this breaks down the clot into smaller fragments which are then circulated through the body and broken down further in other areas of the body (the liver and the kidneys).

The problem is that when this happens on a mass scale, there is a problem in that clotting and then bleeding on a mass scale also occur resulting in consumption of the coagulation factors, and with increased bleeding, this means the patient cannot clot and maintain a clot. This is further discussed below.

The Life threatening bleed

This brings us to the patient who presents with a life threatening bleed.

See the diagram below for the processes that can result in traumatic coagulopathy:

https://ccforum.biomedcentral.com/articles/10.1186/cc12685

Trauma results in tissue damage, which results in three negative effects

1. Cytokine and inflammatory mediator release
2. Blood loss through the damage to the vessels
3. Activation of clotting (and by default, fibrinolysis)

What is really important to understand, is that tranexamic acid alone will NOT save the patient with major haemorrhage, a multi-pronged approach to the management of this patient is vital. This approach should include:

• Control where possible of bleeding with pressure, tourniquets, and splinting as needed
• Limited, or careful fluid administration to the patient with a major bleed
• Limiting crystaloid volume as far as possible
• Starting blood products and/or inotropes earlier rather than later to maintain perfusion to keep the patient alive
• Early and rapid transportation to a facility capable of coping with the patient’s condition

If the patient has possible raised intracranial pressure, the recipe above is slightly different and will be discussed under the guideline update for the patient with raised intracranial pressure.

What we do know, is that in the patient with massive blood loss, when we add tranexamic acid to the care bundle above, early in the patient treatment (the earlier the better), we can affect mortality positively.

What are the recommendations?

1. Tranexamic acid is recommended for administration AS EARLY AS POSSIBLE to the trauma patient who is bleeding or at risk of significant bleeding.

   • At a loading dose of 1g over 10 minutes for adult patients, followed by an infusion of 1g over 8 hours (HPCSA PBEC CPG, 2018)

2. IV Tranexamic acid should be used as soon as possible in patients with major trauma or active, or suspected active bleeding (HPCSA PBEC CPG, 2018)
3. Tranexamic acid should not be used if the time since injury is more than 3 hours (except in special circumstances, such as evidence of hyperfibrinolysis exists)
4. Protocols for the administration of Tranexamic acid should allow for the administration of this mediaction on route to hospital.

What is the effect of this medication on mortality?

The Crash-2 trial (Shakur, et al. 2010) enrolled over 20 000 patients who were admitted with bleeding or thought to be at risk of bleeding, these patients were randomized to one of two groups.

The first group received 1g TXA over 10 minutes followed by a 1g infusion over 8 hours. The second group received placebo at the same time regime as the TXA group (the treating practitioners were not aware if the patient received the medication or placebo). This was administered in the first 8 hours following injury.

The Crash-2 trial (Shakur, et al. 2010) reported the following findings:

• Primary outcome:
  • Mortality at 4 weeks post admission was decreased in the group who received TXA for all patients
  • Risk of death due to bleeding was also reduced in the TXA group.
  • No increased risk of thrombo-embolic events (this means that there was no increase in the risk of clotting in the patients in this study)
• Subgroup analysis (secondary outcome)
  • Patients who received the medication within 1 hour of thier injury, then the risk due to death from bleeding was reduced even further.
  • TXA given at 1-3 hours following injury still had an imporvement in mortality.
  • TXA given after 3 hours did not improve mortality, but actually was associated with increased the risk of death. 

Description of the medication:

• Tranexamic acid (trade name: Cyklocapron)
• Classed as: Anitfibrinolytic agent (refer above for more info)
• Schedule: 4 (please refer to the “understanding scheduling” section for more information)

Pharmacological Action (how does the medication work?)

Tranexamic is a medication that prevents the breakdown of clots (antifibrinolytic), the important thing here is that tranexamic acid DOES NOT create clots, that process happens as it normally would, TXA only prevents the breakdown of existing clots.

How does it do this?

TXA works to inhibit the activation of plasminogen to plasmin, on the diagram below you will see that in order for the clot to be broken down plasminogen (inactive form) needs to be converted to plasmin, and then the process of clot fibrinolysis can occur.

TXA is a competitive inhibitor (it works against) plasminogen activator, and so prevents plasmin from being formed.

Pharmacokinetics (how the medication moves into and out of the body)

TXA is administered to the bleeding trauma patient via IV, this means that all of the dose is immediatly available in the blood after administration.

• TXA travels in the blood almost completely bound to plasminogen
• Less than 5 % of the medication is metabolised, and so there are no by-products or metabolites of the medication after administration
• The medication is eliminated from the body via the kidneys with more than 90% of the drug excreted within 24 hours in most patients (Drugbank. 2018)
• Duration of action is approximatly 3 hours (this is why the infusion is started to maintain the antifibrinolytic effects until bleeding can be controlled) (Sukeik, 2011)

Indications (when should I use it)

When you are treating a bleeding patient, or a patient who you think might be bleeding enough to create a life threat, within the first 3 hours following injury.

• Hypotensive trauma patient with signifigant mechanism of injury and/or ongoing bleeding (HPCSA PBEC CPG. 2018)
• Within the first three hours following injury

Contra-Indications (when should I NOT use it)

The list in red is the list of contrindications that appear on the package insert of this medciation. The list that appears in blue below that is a list of relative contraindaitons, and conditions in which the provider should think a little more carefully about the risk/benefit ratio.

• In patients with acquired defective color vision, since this prohibits measuring one endpoint that should be followed as a measure of toxicity
• In patients with subarachnoid hemorrhage. Anecdotal experience indicates that cerebral edema and cerebral infarction may be caused by CYKLOKAPRON in such patients
• In patients with active intravascular clotting (for example disseminated intravascualr coagulation)
• In patients with hypersensitivity to tranexamic acid or any of the ingredients
• Known history of severe renal failure
• Liver impairment (SAMF, 2014)
• Massive upper renal tract bleed (this is not particularly relevent for the trauma environment as the patient will be bleeding from the trauma and not a renal system issue, but may be relevent in the medical patient) (SAMF, 2014)

Relative Contra-indications/precautions

• Do not delay more urgent critical resuscitation interventions to give TXA (like stopping bleeding, oxygenation, ventilation or any other life saving intervention)
• Be careful in patients at risk of thrombotic complications, e.g. procoagulant disorders, previous DVT / PE
• Renal failure patients in general 

Adverse effects (things that could go wrong if I use it)

Ones we need to worry about for the pre-hospital environment

• Hypotension  when intravenous administration exceeded 1 ml per minute or 100mg/min have been reported (Xanodyne Pharmaceuticals Inc)
• Anaphalaxis is a possible but rare side effect of TXA (6 cases reported)

Other adverse effects

• Gastrointestinal disturbances (nausea, vomiting, cramps)
  • Only found with oral administration of the medication
• Seizure risk seems to increase
  • Specifically in patients undergoing cardiovascular surgery, especially when the medication is administered into the spine/around the spinal nerves (epidural/spinal)
• Increased risk of thrombo-embolism
  • Pulmonary Embolism, DVT and AMI: seems to be related to higher doses (reported in 4 patients who all received high doses (3-24g) daily for a prolonged period of time) (Calapai, et al. 2015), or were medical patients who presented with other risk factors present for thromboembolic disease at the time.
• Myopathy (structural or functional impairment of muscle fibres) with prolonged or chronic use of the medication (also very rare)

Severe adverse reactions to TXA are uncommon, especially in the population of patients treated in the pre-hospital environment. The risks associated with lower doses (as

reccomended below) as acute/single doses increase the safety of this medication.

Packaging

• Clear, colourless solution
• 500mg/5ml (100mg/ml solution)

Dosing

•  Loading dose of 1g/10minutes followed by a 1g over 8 hour infusion

Dosing for paediatric patients

Age	Loading dose (administer within 3 hours)	Subsequent dose
≥12 years::adult protocol	1 g intravenously over 10 minutes	1 g intravenous infusion over 8 hours
<12 years	15 mg/kg intravenously over 10 minutes (maximum dose 1 g)	2 mg/kg/hr intravenous infusion over 8 hours or until bleeding stops

The Hospital for Sick Children Massive Hemorrhage Protocol for the use of tranexamic acid in pediatric trauma. April 2014. Adapted from Royal College of Paediatrics and Child Health: Evidence statement – Major trauma and the use of tranexamic acid in children.

TO ACCESS CPD POINTS FOR THIS ACTIVITY (SA only):

please email training@aiem.co.za

References:

• Calapai G, Gangemi S, Mannucci C, Miniullo PL, Casciaro M, et al. 2015. Systematic Review of Tranexamic Acid Adverse Reactions . J Pharmacovigilance 3:171. doi:10.4172/2329-6887.1000171
• Drugbank. 2018. Tranexamic Acid. available online: https://www.drugbank.ca/drugs/DB00302. Accessed 06/09/2018
• Royal College of Paeditrics and Child Health Care. 2012. Evidence Statement

  Major trauma and the use of tranexamic acid in children. Available Onlne: https://www.rcem.ac.uk/docs/External%20Guidance/10k.%20Major%20trauma%20and%20the%20use%20of%20tranexamic%20acid%20in%20children%20Evidence%20statement%20(RCPCH,%20Nov%202012).pdf [accessed 06/09/2018]

• Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, El-Sayed H, Gogichaishvili T, Gupta S, Herrera J, Hunt B, Iribhogbe P, Izurieta M, Khamis H, Komolafe E, Marrero MA, Mejía-Mantilla J, Miranda J, Morales C, Olaomi O, Olldashi F, Perel P, Peto R, Ramana PV, Ravi RR, Yutthakasemsunt S. 2010. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010, 376: 23-32.
• SAMF. 2014. South African Medicines Formulary. Division of Clinical Pharmacology, Faculty of Health Sciences, UCT. Health and Medical Publishing Group of SA.
• Sukeik M, Alshryda S, Haddad FS, Mason JM. 2011. Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement. Journal of Bone and Joint Surgery

  Series B. 2011;93 B(1):39-46.

• “Product Information. LYSTEDA (tranexamic acid).” Xanodyne Pharmaceuticals Inc, Newport, KY

Post by @epicEMC

Advance Directives

Guest post by Darren Van Zyl 

I’ll make this really simple and start with the punch line: They’re called ADVANCE DIRECTIVES and they are all VALID. 

 The end.

But I better explain… So here goes: (Please keep reading this is IMPORTANT!). Pay attention (JZ, 2016) ….

(For the purposes of this paper we are referring to your garden variety patient who is legally and mentally competent to consent to (and therefore refuse) treatment. Making a bad decision / one that the practitioner disagrees with does not make the patient mentally incompetent. (For more information on informed consent and the requirements: (http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/ethical_rules/Booklet%204%20Informed%20Consent%20September%20%202016.pdf )

Four Principle approach to Medical Ethics

There are several models / approaches to medical ethics. The Four Principle Approach is very popular and useful to explain advance directives. The four principles are:

• Autonomy: Patients have a right to consent to / refuse treatment after they have been informed of the risks and benefits of either. Legally competent persons who can consent to treatment may also refuse treatment EVEN if this results in harm to self / death. Over-riding this principle is called Medical Paternalism and is not acceptable / legal in South Africa (Except in very specific situations, which for the purposes of this paper, are not going to be considered).
• Beneficence: This means that practitioners should act in the best interests of the patient.
• Non-maleficence: “Do no harm”: Always act to cause the least harm to the patient.
• Justice: Treating all patients equally regardless of religion, race, gender, etc. Being non-discriminatory.

Now, the problem comes in when the above principles conflict with each other. For example: Patient has refused treatment (autonomy) and this may result in harm / death (and might not even be in his / her best interests)…. Well, in Western society (including South Africa) the principle of autonomy over-rides the others and the patient’s wishes MUST be respected. It’s actually that simple.

You also can’t wait for the patient to deteriorate / get to the point where they can no longer communicate and then over-ride their previously communicated decision(s)!

And this is what makes advance directives valid: The principle of autonomy.

Types of advance directives and terminology

There are many terms for advance directives and the wording often causes confusion. BUT, essentially these can be issued / declared in three ways:

• By the patient him / herself. This is obviously the most ideal situation: communicate with the patient about his / her wishes, if possible, before the situation / condition deteriorates;
• By a surrogate for the patient (See below); and
• The medical team involved in the patient’s care (Specifically the physician in charge of the patient). This is specifically done when the principle of futility applies and further treatment would have no benefit and may even be unethical.

 

In all three cases documentation of the decision is essential and should be done as soon as possible. Verbal decisions on the part of the patient / surrogate are acceptable but should be recorded in the clinical notes (With names of witnesses to add extra vooma, although this is not strictly a requirement).

So let’s have a look at some popular terms that are used for advance directives and elucidate any differences:

• No not resuscitate (DNR) order: This is probably the most popular and common term. One of the challenges with this term is defining the word “resuscitation” because this could mean anything from rehydrating a dehydrated patient to CPR; and everything in between. The trend is to define the exact procedures that the patient is refusing and many now speak of “No CPR” orders. Some of the European literature is using the term “AND” (Allow natural death).
• Living will: This form of advance directive is usually issued by the patient and the wording is pretty standard (Google it) although modifications can be made and specifications stated. The standard wording starts with the implication that the document only comes into effect when “there is no hope” (continued treatment is FUTILE)… So this usually does not cover CPR / resuscitation or emergencies; although no CPR can be a condition.

Patient consent, surrogates, and emergencies

What do you do when you cannot communicate with the patient because they are incapacitated? Well, if he / she has already communicated their wishes verbally or in writing you respect any decisions made at that time. Otherwise, I can’t say it better than the current National Health Act: So I’m just going to copy and paste Chapter 2, Section 7 of the Act which tells you in which order to listen to the relatives:

A few things:

• In South Africa the definition of a “Partner” is simply “Living together as if married” (McQuoid-Mason & Dada, 2011);
• Item e above makes it very clear that if a patient has expressly denied consent (even if by conduct) then a practitioner may not over-ride this decision when they patient becomes further incapacitated and an emergency arises;
• We cannot go around questioning the motives of patient surrogates who refuse treatment (CPR or resuscitation) on behalf of their incapacitated relative. Unless there are obvious circumstances not to do so practitioners should take the wishes of the relatives / surrogates at face value and document such;
• Another copy and paste: The booklet on “Withdrawing and Withholding Treatment” published by the HPCSA states:

Conclusion

Please respect your patients’ decisions! Communicate! Document!

Read up on all of this BEFORE it happens.

Don’t call me at 2am because you didn’t: I’m sleeping.

And use the following useful links (Directly off the HPCSA website):

• National Health Act:

 http://www.hpcsa.co.za/uploads/editor/UserFiles/National%20Health%20Act.pdf

•  HPCSA Booklet 4: Informed Consent:

http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/ethical_rules/Booklet%204%20Informed%20Consent%20September%20%202016.pdf

•  HPCSA Booklet 7: Withholding and Withdrawing of Treatment (Read this one if you have limited time / concentration):

 http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/conduct_ethics/Booklet%207.pdf

 

[This is the self-promoting bit: Darren is an Advanced Life Support Paramedic who also completed a year long Certificate in Medicine and Law (UNISA). During this time he got to pick the brains of some of the Country’s medico-legal gurus and can therefore assure you that he wasn’t making up the information in this article]

 

In LIFE and DEATH

Palliative Care in the Emergency Department

“Death is often seen as a failure to keep people alive rather than a natural dignified end to life” (1)

Coping with death is difficult for anyone, including medical care practitioners. The super-hero mentality (emergency physicians (EP) in particular suffer from this disorder) makes encountering an end-of-life situation confusing, anxiety-inducing and unnerving. Unfortunately with more and more terminally ill patients presenting to the emergency department (ED), EPs need to acquire skills in comfort and palliative care.

Patients diagnosed with life-threatening illnesses should from time of diagnosis be initiated on a treatment path of palliative care. EPs should always be alert for this patient population as they do present to the ED. Commonly they present seeking symptom control or they are brought in by distraught family members in crisis. As an EP you will have to deal with both in a caring, compassionate yet professional manner.

There are many myths surrounding management of these patients. Here are three which I will debunk:

• Palliative care implies doing nothing for the patient
• Palliative care is someone else’s problem (not the EP’s problem)
• Opioids hastens death and should only be prescribed with extreme caution

The WHO’s definition of palliative care is  “An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (2)

Palliative care therefore does NOT mean doing nothing for the patient. It is a very active form of care which requires EPs to seek out and attend to those symptoms that may cause patient distress.

Another other common myth is that palliative care cannot or should not be initiated/ implemented in the ED. It’s for the wards, the palliative care clinic or a hospice. WHO deliberately uses the terminology- life threatening illness (see the above definition) – so as to illustrate the point that these patients require palliative care even before they reach the terminal stage of their illness.

Common complaints will be shortness of breath, pain, agitation or delirium which can easily be addressed in the ED.

Treating some of the symptoms may require administering opioids, which leads us to our third myth: Opioids given for symptom control may hasten death. This is the so-called “double effect” (3).

Many practitioners shy away from administering opioids for fear of hastening death therefore leaving patients to suffer. Palliated patients are often on fairly high doses of oral outpatient opioids and tolerate them without life threatening side effects. The goal in the ED is to convert their oral outpatient doses to the intravenous forms, to adjust suboptimal dosage or to supplement current analgeisa.

Ultimately a significant part of palliative care is just talking. Talking to patients and their families.

Starting conversations

When the patient arrives in the ED assess the patient as you would any other patient. Provide appropriate initial supportive care until you get a full background history of the patients diagnosis and care plan. Do not be distracted by family members or the mutterings of fellow staff members discouraging initial thorough assessment and care. Providing initial supportive care often buys you time for further information gathering. When you are ready to engage with the patient and/or the family ensure you have the following:

1. an appropriate location
2. a structured approach to discussing all the pertinent points regarding the patient and their care plan
3. a colleague to accompany you

 

SILVER is an easy mnemonic (there are many others) that I believe provides a structured approach and covers all the pertinent aspects of such a conversation(1).

Seek Information

• How are the people present related to the patient?
• Who can make decisions on behalf of the patient (e.g. spouse or legal representative etc)
• Who will be the family spokesperson? You may not always be able to speak to the whole family and speaking to different people is far from ideal.
• If there’s a relative with a medical background that’s a bonus. Do not let this intimidate you – it’s actually very beneficial.

The initial part of the conversation should allow  the family to do most of the talking. Assist them with open ended questions:

What do you know/understand about the patient’s condition? Do you have any medical reports from previous consultations? Previous treatment plans? If they struggle, follow up with even more basic questions: Who stays with the patient? Who brings the patient for their follow ups? That usually gets things going.

The most important information to illicit from the family/patient should be: What are the expectations of this visit?

Life Values

Patients presenting to the South African public healthcare sector often do not have advanced care directives. For a patient without a directive stimulate conversations which assess their life values or personal wishes. Listen carefully; patients may not articulate themselves in ways which may be culturally recognizable to you. Ask clarity seeking questions. Get help.

If you have access to the patient’s file, read through it for clues. Multiple refusal of hospital treatment forms? A documented discussion with another doctor previously? Include these in your conversation.

Educate

At this point you should have some sense of the patients’ background illness, prognosis and wishes. Educate the family about the expected trajectory of the specific diagnosis/ disease. Mind your language. Do not be offensive, antagonistic or patriarchal but provide the family with medical facts. Speak clearly in understandable language. This is a critical stage in the conversation because from here you can establish and implement realistic goals of care.

Things you might say: “From what I have heard (or read in the file), your family member (name) is suffering from a life-threatening illness. An illness that will eventually cause them to die.”

Pause. Assess response. Continue

“In these types of situations the treatment we offer is that which keeps (name of the loved one) comfortable. None of the treatment will be life saving. We cannot reverse the path of the disease. My recommendation is to provide analgesia, sedation etc according to their needs.”

Pause. Assess for response. Ask for questions

Do not be offended or scared if the family asks for a second opinion. In SA it’s part of the patients rights charter to receive a second opinion(4). Secondly let the family satisfy themselves that they did all they could for their relative and that later they do not get stuck in the guilt stage of the grieving process.

Respond

Answer their questions as best as you can. Do not get caught up in predicting times or dates of death. Respond to their emotions with compassion and empathy, even if their emotions are fear and/or anger. Do not lose your composure. If things do get out of hand solicit calmer family members to assist with relatives who may be out of control or call in security. (As much as you are empathetic with the family you still have the duty to the safety of yourself, other patients and staff in the unit)

Respond to your own emotions as well. Take a moment to yourself after speaking to the family. If you need to cry privately allow yourself to do so. If you need a quick chat with your own family, do so. Refill your own emotional tank before returning to the patients’ side.

Palliative and hospice care fellowships are available in North America and some European countries. There is so much literature available regarding this type of medical care in the ED. Arm yourself with up to date information and I guarantee that both you and the family will come out of this mental space with some level of satisfaction despite the obvious challenges.

 

References

1. https://emergencymedicinecases.com/end-of-life-care-in-emergency-medicine/

2. WHO. Definition of Palliative Care

3. Fohr SA. The double effect of pain medication:separating myth from reality. J Palliat      Med 1998 Winter;1(4):315-283

4. HPCSA.Guidelines for Good Practice in Health Care Professions. Booklet 3. Patient’s Rights Charter

Post by Kamo Molokoane @drhomie

Distraction and Attraction

These are both seemingly straightforward cases. Both trauma related issues and possible complications. It is easy to fall into the trap of trying to refer the patient on to someone else, to make it someone else’s problem.

But one of the distinguishing features of Emergency Medicine is that we get to solve puzzles and seek that which others may miss. Another salient characteristic required in EM  is to be open-minded and adaptable. The undifferentiated patient is the norm, and an un-biased approach is key. Early biased labelling of patients can be detrimental to their health.

A doctor from othopaedics assesses patient 1 and says there is no obvious spinal level, and recommends that the patient should be reviewed by someone else.

By this time the ED has slowed down a bit and a new pair of eyes is cast upon the patient. He seems to be slightly tachypnoiec. A blood gas is done which reveals a severe metabolic acidosis, hyperkalaemia, and hyponatraemia. The hyperkalaeimia is refractory despite multiple potassium shifts. A U&E reveals acute kidney injury. This is possibly an adrenal insufficiency as well. He is transferred to another center for emergent dialysis.

Instead of Patient 2 being sent home, he is triaged and reviewed. He has photophobia and intermittent fever. He has severe neck stiffness, and a positive LP for meningitis.

In both these cases, life threatening medical conditions were masked behind the history of trauma. This lead to delays in diagnosis due to anchoring bias or misdirection.Magicians use misdirection to prevent you from realizing the methods used to create a magical effect, thereby allowing you to experience an apparently impossible event. ²      Most people are aware that this is the way in which magicians fool us into believing their magic tricks. It is often so easy and exciting to be drawn in by these masters of misdirection. In medicine, is it possible that we also often fall prey to similar misdirection in the form of cognitive bias?
The pitfalls of cognitive bias is a topic often highlighted in emergency medicine. When delving into the methods of misdirection used by magicians, there are two which we can easily fall prey to in the emergency department: distraction and attraction.It is easy to become distracted when several things are happening at the same time. This is an everyday occurrence in the ED: the desire to “push the queue”;  to make appropriate disposition plans for our patients; trying to listen and attend to students, other staff; multiple patients at once; thinking about that phone call that needs to be made; and trying to time that much-needed bathroom break. The list goes on and on. In an observational study conducted at two Swedish emergency departments, the interruption rate was 5.1 interruptions per hour⁴, which is about 1 interruption every 11 minutes. There are no studies quantifying the numbers in a busy South African ED. But from personal experience, the interruptions are often more frequent.These two cases provided the reminder to be vigilant of cognitive biases in the ED. We need to be careful and attentive to the constant distractions and interruptions. We need to be mindful of fixating on only a specific portion of information. The individual who initially triages the patient may often not get the full history or  relevant information. Just because a patient is triaged in a certain direction, does not mean they always belong there. This is one of the great aspects of emergency medicine; solving the puzzle and not being fooled by the magician.

Picture credit  Lure. Nick Tackaberry. Flickr.com. Oct 2014

References

1. A Mortal Battle with Four Hour Medicine. Johnston M. LITFL. Blog post updated May 2016
2. A psychologically-based taxonomy of misdirection. Kuhn G, Caffaratti HA, Teszka R, Rensink RA. Front Psychol. 2014; 5: 1392
3. Distraction. Merriam-Webster.com. June 2017
4. Interruptions in emergency department work: an observational and interview study. Berg LN et al. BMJ Qual Saf. 2013; 22(8): 656-63

Interesting articles related to the subject

• From Mindless to Mindful Practice – Cognitive Bias and Clinical Decision Making  Croskerry P. N Eng J Med. 2013; 368 (36):2445-2448
• Sonar Beams Deflecting Cognitive Error Stephen V.  BadEM. blogpost July 2015
• Cognitive Decision Making and Medical Error. Sinclair D, Hicks C, Chartier L, Helman A. Emergency Medical Cases. Episode 11. blogpost Feb 2011

Blog post by Kylen Swartzberg @kylenswartzberg

Peer reviewed by @QuirkyMD

Skills Training

Earlier this year, I had the privilege of attending a Teaching Course in Cape Town, presented by the Teaching CoOpTeam  #TTCCT18.

I was introduced to Peyton’s Four-Step Approach to Skills Training – of which I am now an avid supporter.

This method has been recommended by our surgical colleagues for the longest time now ….

Having been on the unfortunate receiving end of the time-old “see one, do one, teach one” during my medical training, I am delighted to find an educationally sound alternative to that particular brand of academic torture.

I have been told by various teachers that “practice makes perfect” and “perfect practice makes perfect”. But there is much more to learning a skill.

The key to getting better at any technical skill is deliberate practice.

Star musicians and athletes improve by focused and conscious effort. Clinicians can also refine technical skills by mindful and deliberate practice.

The process of transformation for unconscious novice to competent practitioner is not necessarily rapid or easy. It is enhanced by a skilled coach providing insightful and constructive feedback.

The Four-Step approach incorporates deliberate practice into effective skills training.  It is a powerful tool in medical education that I would like to encourage you to add to your armamentarium.

Photo by Element5 Digital on Unsplash

Other resources

• EMCrit Podcast 211. Expertise with Anders Ericsson Blog by Scott Weingart. Oct 2017.
• EMCrit Podcast 212. Thoughts on Deliberate Practice and Expertise.  Blog by Scott Weingart. Nov 2017
• LITFL. Life in the Fast Lane Medical Blog. Deliberate Practice Nickson. April 2017

References

1. Peyton J. Teaching and learning in medical practice. Peyton J (Ed). Manticore Europe, Ltd. 1998 :171–80
2. Lake FR, Hamdorf JM. Teaching on the run tips 5: teaching a skill. MJA. 2004. 18 (6): 327-328
3. Green GM, Chen EH. Top 10 ideas to improve your bedside teaching in a busy emergency department. Emerg Med J. 2014; 0: 1-2
4. Krautter M, Wyrich P, Schultz JH et al.Effects of Peyton’s Four-Step Approach on Objective Performance Measures in Technical Skills Training: A Controlled Trial. Teaching and Learning in Medicine: An International Journal, 23:3, 244-250

Post by @QuirkyMD

Peer Reviewed by @epicEMC

 

 

Inside the bubble of #BadEMFest18

To say that last week’s #BadEMFest18 changed my life would be really dramatic. But sometimes I am dramatic…

#BadEMFest18 was the most amazing collection of incredible experiences I could ever have asked for in short 4 days. From the caliber of speakers, topics, people and interactions to the food, glamping set up and programme, this conference changed the way I see myself, EM and most importantly AFRICAN EM.

I had the amazing opportunity to share a very short version of a colourful story with the 150 odd (and I say odd more because we were all equally odd) delegates. It was the first time I had shared any of this story face to face, with so many people.

Evidence of the other “odd” delegates

The story I want to share here though is not the story I shared on the stage or in the talk, although to understand how the experience has impacted me, there should be some context.

I was born 31 years ago Kayleigh Jane Lachenicht, but shortly (ok so a few years) later started noticing that I was not the same as all the other little girls I knew. I was different. Different enough to cause discomfort every time I had to line up with the girls, and hold the hand of the boy next to me to make sure we walked straight. Different enough to be asked repeatedly to leave the ladies bathroom as an 8 year old because I looked like a boy. Different enough to shave my hair short, and swim in boys trunks, and climb trees and play cricket at school. Different enough to be asked if I was sure I was at the correct school in my first year of high school, as concerned parents realised their daughters would be going on camp with a “boy”, or worse. Different enough to realise at the age of 30 that perhaps the difference between me and other woman, was that I am not a woman, different enough to start on a pathway to a more honest, more comfortable version of myself. Through this interaction, I learned a lot about myself and the perspective of the patient in the interaction with medical professionals, and found that the system as well as providers lacked training and knowledge to cope with a patient who is different.

So I stood on stage at #BadEMFest18 and literally flung myself out of the transgender closet, in front of 150 people most of whom I didn’t know. I asked them to consider what it might be like to be forced into something that they were not comfortable with for the rest of their lives, based on how society perceived them.

I asked them to imagine a world where every time they enter a bathroom, their motives are questioned.

I asked them to imagine walking into a hospital and having to explain to every staff member you come into contact with why your name and your appearance don’t match, and answer intrusive questions about genitalia that no one would ever ask a “normal” patient.

I asked them to be kind, and inclusive, to think a little less about how uncomfortable it may be to treat a transgender person, and more carefully about how uncomfortable it might be to be a transgender person in the ED.

And they did

But they also did more than just think about their patients,I could not sum it up better than @aalenyo when she said “All the nice people do Emergency Care”.

I finished my talk, jumped off the stage at the end of the session, thanked my fellow speakers for that session, avoided eye contact. I had a Brene Brown vulnerability hangover moment,  it was instantaneous. I wondered why on earth I had just done that. Come out to so many people I didn’t know, and would have to spend the next 4 days with. Why had I taken such a big risk, in front of many of my Hero’s in EM? What on Earth was I thinking??

There is something to be said for living incognito… letting people guess who you are, or what you are. Specifically with regard to gender, because its so awkward to ask, and so far out of the usual experience of most people, if you don’t volunteer information, you don’t usually get asked. Not directly anyway.

But when you burst through the closest doors in glorious rainbow colours, suddenly its impossible to hide anymore. This is where I found myself in the blur following that afternoon session.

And this is where the magic began. From the moment I stepped off that stage, those #BadEMFest18 people (i wanted to call them BadEMFesters but it sounds a bit septic) accepted me. As I was. In the words of my favourite gender activist (IO Tillet-Wright) “they accepted me for just exactly who I said I was”.

People made eye contact, shook my hand and didn’t look away awkwardly when I spoke. People engaged openly with me, instead of avoiding me. Not once in my time at BadEM did I have discomfort or unease about walking into a bathroom (any bathroom), or aiming for the ladies stalls when I went to shower, or men’s bathroom when the queue was too long. I didn’t have awkward he/she/it moments because everyone was so aware of being careful to use gender neutral terms. I didn’t have to explain why my name was different to the one most people knew me by in the past, or that i wasn’t sick, rather that my voice was busy dropping.

For 4 glorious days, I didn’t have to explain myself once to a single person.  The other incredibly liberating feeling was that me being transgender was not the most interesting thing about me. It was something that I had managed to get out of the way in the first hour of interaction, and that was it.

#BadEMFest18 gave me this glimmer of what a future could be like if we stop trying to define each other by the things that make us different, and look to the things that make us human, a concept that was repeated as a theme throughout the festival as the idea of UBUNTU. Its not just about gender, it is about anything that makes us different.

I will be taking a few things home with me after #BadEMFest

• There is nothing that can be thrown at the people of EM, that they will not adapt to
• Echoed by so many others at the festival “these are my people” 
• People want to understand rather than judge, and the only way to create understanding is open, vulnerable communication
• Ubuntu defines African EM, it is our greatest strength (we are through others)
• Its OK to be who you are, even if the rest of the world doesn’t quite get it

For some resources on how to be a trans-ally and some more information on what Transgender means, see the links below, a blog summarizing the major points of the talk will follow soon!

 

1. Hope, J. and Tadros, A. 2015. Transgender patients iin the ED. Emergency Physicians Monthly. [available online] http://epmonthly.com/article/transgender-patients-in-the-ed/
2. Decker Moss. 2013. TedX Columbus. https://www.youtube.com/watch?v=nOmstbKVebM
3. Shaffer, et al. 2005. Transgender Patients: Implications for ED Policy and Practice. Journal of Emergency Nurses. [available online] https://myhs.ucdmc.ucdavis.edu/documents/41620/0/Transgender+patients+implications+for+emergency+department+police+and+practice.pdf/d7c19382-ee72-4a1b-9ef6-5648af446084
4. Straker, et al. 2017. Transgender and Gender Nonconforming in Emergency Departments: A Qualitative Report of Patient Experiences. Transgender Health. [available online] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367487/
5. Ouyang, H. 2017. A Transgender Learning Gap in the Emergency Room. The New York Times. [available online] https://www.nytimes.com/2017/04/13/well/live/a-transgender-learning-gap-in-the-emergency-room.html
6. Brene Brown. 2011. TedX Houston. The Power of Vulnerability. [available online] https://www.ted.com/talks/brene_brown_on_vulnerability

The Interconnectedness of things

Great article on an approach to palliative and end-of-life care.

Shared at #BadEMFest18

The 5 minute approach for Goals of Care in the ED from David Wang’s article.

Another resource (with accompanying podcast) for diving straight into this topic.

This is a great article on end of life care in the ICU setting.

 

 

 

Communication is key.

“The term holistic

refers to my conviction that what we are concerned with here is the 

fundamental interconnectedness of all things”

– Dirk Gently, Douglas Adams.

 

Reading list

1. Wang DH. Beyond Code Status: Palliative Care in the Emergency Department. Ann Emerg Med. 2017; 69: 437-443 Beyond Code Status
2. Emergency Medicine Cases – Episode 70 End-of-life Care in Emergency Medicine
3. Cook D, Rocker G. Dying with Dignity in the Intensive Care Unit. NEMJ. 2014. 370:2506-2514 Dignity with Dying in the ICU
4. McQuoid-Mason DJ. Withholding or withdrawing treatment and palliative treatment hastening death: The real reason why doctors are not held legally liable for murder. 2014; 104 (2);102-103 Withholding or withdrawing treatment
5. McEwan A, Silverberg JZ. Palliative Care in the Emergency Department. Emerg Med Clin N Am. 2016. 667-685. Palliative Care in the ED
6. Mierendorf SM, Gidvani V. Palliative Care in the Emergency Department. Permanente Journal. 2014. 18(2): 77-79 Palliative Care in the Emergency Department
7. Royal College of Nursing. Typical Death Trajectory
8. ACEP. Palliative Medicine Section. Simple Palliative Care Toolkit
9. UW School of Medicine. End of Life Research Programme. Communication Tools.  Accessed 2018. Communication Tools
10. Psirides A. Das SMACC. 2017. conference presentation. “Everything” at the End of Life
11. Gustav-Klimt.com The Tree of Life

Post by @QuirkyMD