Attended another training/teaching day sponsored/arranged by the deanery – was a very, VERY useful and informative day – and though it dragged on for hours, it was very interesting and explained quite a few things that I had not known previously – gist of the major salient points of each of the talks are listed below – may expand on 1 or more of these topics in the near future – so inspiring!
There were 4 speakers
PUBLIC HEALTH PROMOTION – how to explore facets of public health while in ED, because most people interact with someone in the ED, and that may be the only point of medical contact they have had up until that point.
smoking cessation, weight loss, exercise, pre-diabetes identification –
screening programs are fixed, inflexible , protocoled care, applied across a particular age group- safeguarding, frailty, VTE, dementia screening, hypertension, alcohol issues, obesity, domestic violence, smoking
case scenario of overweight person presents with orthopaedic problems, upon discharge do you speak to them about their weight? as an ED physician
case scenario of unwell child who has never been vaccinated – what will you do? How do you approach the subject with the parent, or do you even approach it at all?
case scenario of alcoholic patient with head injury – would you address the alcohol issue? (unit is 8 gm or 10 ml) 25 in whiskey, 10 in wine and 40 in spirigel
alcohol problems discussion
(having withdrawal symptoms when not drinking is being dependant on alcohol)
who should you be screening for problem drinking – selected presentations
how do you ask for alcohol intake?- use PAT scale – CAGE questions are useful in establish alcohol related problems.
important because intervention is helpful
PUBLIC HEALTH AND EMERGENCY MEDICINE
as doctors/physicians it is our ethical duty to reduce injury and illness, wherever we interact with patients.
we tend to have more interaction with the general public
you are more likely to see violence/injuries than the police – some studies show more than 3 times!
how can you help as doctors? injury survielance, mandatory reporting, better design, improve treatment, collate data and improve conditions – location of assault, date/time of assault, weapon, age
crime rates went down because of data collected due to targeted policing
what are barriers to implementation? – police expectations, IT issues, governance, receptionist, leads
pitfalls – mission creep, fatigue, silos
conclusion? violent injury surveillance and control is effective in reducing violence. implementation can be challenging
QI (Quality Improvement)
audits are important but rarely work
why do they fail? – tick box exercise, temporary staff, lack of feedback, career advancement a priority rather than care advancement, lack of collective responsibility (if your rotation ends, the audit ends with you, no continuity)
has now become quality assurance rather than improvement. “maintaining/meeting set standards” rather than “improving the standards”
RCEM guide to QI is the QI bible.
do less, do it better
choose a standard to improve:is it important?, is it fundamental?, is it fixable?
talk to the stakeholders (nursing staff, frontline staff, triage, juniors, etc), ask them why this is not happening – how to improve conditions?
measure the standard
intervene to implement a change, and then re-measure after a suitable timeframe.
establish or convey a sense of crisis – reiterate how important/imperative this measurement is.
CARDIOLOGY – ACS
definition of ACS
reiteration of importance of history – onset and character
repeat ecg, compare with previous
do not delay treatment waiting for biomarkers in “cardiac-sounding” chest pain.
consider bedside imaging if hemodynamic instability
escalate appropriately, consider involvement of tertiary care
dissection a differential? CT aorta stat (discussion about d dimer as useful in this scenario – some people say a negative d dimer rules out a dissection – research shows that is not the case)
management – analgesia+dual antiplatelet therapy, GP2B3AI, antihypertensives (b blockers) ACEI. statin, REGARDLESS OFWHETHER AN INTERVENTION TAKES PLACE LATER ON OR NOT, GIVE THE MEDICAL TREATMENT. if already on aspirin, 300 or 225 of aspirin either way doesn’t matter, 600 of clopidogrel and 80 of tigacrelor (not to use if warfarinized – MAKE SURE INR IS THERAPEUTIC)
immediate management – angio +/- PCI (for STEMI within window, ongoing symptoms, cariogenic shock, for NSTEMI – hemodynamic instability, ongoing schema or shock, IF REFRACTORY TO INITIAL MEDICAL THERAPY)
high risk/labile/recurrent schema – urgent angio
all others get routine angio
12 hours stemi – def PPCI, greater than 12 hours – if symptoms, PPCI, greater than 48 hours – no PPCI.
<30 mins door in door out in non pic centers. <60 mins door to wire crossing in PCI centre. and LBBB/RBBB considered equally. no o2 if >90 sats on RA.
consider CPAP, IF DISTRESS. iv amiodarone for AF, Look for hyperglycaemic states, MRA if CF.
if unable to decide if LBBB is new or old, compare to previous but if none available to compare, look at the patient. vast majority are not acute, unless they’re in cariogenic shock.
may be a symptom of sepsis – does not mean primary focus is gastrointestinal- particularly in the elderly
rotavirus most common in children – vaccine now available, rotarix at 8 and 12 weeks, seasonal
COD – dehydration/acidosis
use dioralyte instead of pure water for replacement. diluted juice.
norovirus and c.difficile has to be reported.
electrolyte disturbances – hypo/hypernatremia, acidosis, acidosis, hypoklemia (3-3.5: oral replacement or 20/1000 ml saline over 2-3 hours; 2.5-3: 40/litre over 4-6 hours; <2.5 or with ecg changes at any low level such as prolonged QTC, flat t waves at risk of arrhythmia; <1.5 will be paralysed, muscular weakness, apneoic. ECG-CARDIAC MONITOR-CONSIDER RESUS
discussion about hyponatremia and its management
multiple cases discussed and shown, along with rhythm strips, interactive 1 hour session with responses from the audience tailoring the talk. VERY interesting.