1) RCEM President address – pertinent points extolled were: good practice guide; duty of candor; work ethics; reiterated how the quality of care that we provide to patients has improved over the years; members have gone from 7 to 7500 in a matter of a few years!
He also talked about the ED exit block, what problems it created and how it wasn’t really the department itself that caused the block, but the flow out of the department, and that was basically a matter of funding and resources.
He addressed a few ‘elephants’ in the room – key concerns were the fact that demand has increased, with a 30 percent rise in ed attendances in 12 years; variations in staffing, variations in systems, variations in support/behavior of management/colleagues. He re-iterated that improvement starts at leadership at the top. Creating environment for support, momentum, culture was key in establishing good support systems for all staff – also quoted by Edward Demming in stressing the need to ‘reduce variation for optimum management.’
high quality improvement projects key to chip away at bad or lesser effective practices.
workforce is key- planning. need multidisciplinary workforce with senior decision maker layer on top, consultant cover has increased in past few years, still only about halfway there.
grow it to create depth and breadth, create strategies to reduce attrition in training, maximise retention for consultants, increase training numbers by 33 pc (80 pc from baseline to 400/year for 4 years)
plans to start dedicated leadership programs
plans to start clinical educator programs
plans to start and further increase fellowships – geriatric EM, humanitarian EM, ambulatory EM.
he also spoke about how to retain older consultants 50-55 age before the retirement age, because it can get tiring, as well as ways to support the new generation of EM consultants.
2- MacMillan Nurse John Sheridan – Palliative care
He spoke about and clarified a few terms about end of life, palliative care. He defined palliative care as ‘living as well as possible for as long as possible (usually 12 months)
33 percent bed base in every hosp, palliative at any time.
patients usually end up in ED due to poor planning, portrayal in media
usually PC is thought to be malignancy related. wrong assumption. can be any disease causing possible/probable death in 12 months. gp should e informed.
on call OOH Palliative care opinion always available everywhere
think about an emergency care plan upon discharge or transfer of care to home or other service. contact district nurses. dedicated palliative ambulance, dedicated palliative care nurses, bellflowers, deciding right app
3- PHEM/ED consultant – shared scenario – video of resuscitation of stabbing victim – cardiac tamponade relieved prehospital. making unexpected survivors to expected survivors.
4 – trauma network – geography, what it entails, MTC, ambulance services (usually multiple, coordinating between them, air ambulance.overnight cover. approved by nhs england.
take on calls for advice. every aspect of clinical journey. clinical guidelines education.training, sui, audits, make sure standards are maintained across the board.
5 – GEM
frailty scoring – E FRAILTY INDEX./edmonton frailty scale/CHAMP/rockwood or clinical frailty score
why? multidisciplinary. NNT 13-17 TO AVOID DEATH OR ADMISSION TO CARE HOME WITHIN 6 MONTHS. vs 17 for stroke thromb 42 for aspirin post-MI.
admtted vs discharged from ED – improves care for both/further planning etc
frail = complex. (plus sheer numbers in ED adds to danger for frail patients)
delirium – VERY IMPORTANT. getting it wrong – due to our perceptipn, helpfulness of older person, lack of family carer with patient – 11 pc screening completed in 2015 audit. if missed in ed, 70 percent missed during rest of admission
every time you chicken out of a DNACPR discussion god kills a kitten.
dangers of non specific general vague presentations – over 80? falls, confusion, weakness, fatigues, inability to cope – falls, usually multifctoria. MI AND PNEUMONIA DONT PRESENT IN ELDERLY TYPICALLY
major trauma USUALLY CALLED SILVER TRAUMA – is usually NAN DOWN. likely to be seen in trauma units. likely to be seen by juniors.
future of GEM
6- EM Trainee presentations x 3
dislocated shoulder management – shoulder relocation bench? 77 percent reduction successful without sedation
stroke vs stroke mimics (how to differentiate)
ketamine sedation audit
7 – “Tactical team medics”
8 – GP with EM specialist interest
9 – ACP sharing experiences and progress
10 – ALS – Cardiac arrest beyond the algorithm – ITU/ANAESTHETICS CONSULTANT
children – cpr training/sweden/danish/germany/france
immediate bystander cps good – improved outcomes
less than 60 years of age good outcome
e-cpr no confirmed survivors
summary – routine application of also not leading to early rosc
focus should shift entirely in certain cases
charge defib early
always use echo
think in parallel
11 – burnout
1/3 will have depressive episode
1/12 will consider suicide
shared personal experience
maslach burnout inventory
depersonalisation – cynicism, sarcasm, compassion fatigue
exhaustion – not sure how much longer i can go on
lack of efficacy
sources of burnout – ourselves, blame culture, NHS structure complexity
positivity of juggling this stress of work
negative stress – same things same sort of day totally different mood
how to handle the stress – time management, checklist – headspace – (physical/emotional/spiritual banks)
events + rections = outcome
let it go
12 – keynote speaker – hospital response to a major incident
when you fail to prepare you prepare to fail