The perks of PERC

The really worrying question sometimes arises (or depending on your luck, most times arises) while you are in an ED, and you see a patient who comes in with ‘some chest pain’ that’s maybe a little pleuritic in nature, but pleuritic chest pain could result from a punch to the chest, or if you cough too hard or too long (I unfortunately speak from experience!) and you don’t know what to do and someone’s already done a D-Dimer on the patient’s initial bloods as they were triaged, before you saw them, if you are lucky enough to work in a department as great as ours (or unlucky, depending on how you view the over-testing of D-Dimers!) – I have been handed the most amazing tool: the PERC score, or the Pulmonary Embolism Rule-out Criteria. For those of you already aware of the existence of such a magic wand – bravissimo and kudos to you, and no need to read on any further. For the ones like me who until very recently hadn’t even heard of it, please proceed further.

Patients who present with clinically low risk for development of a PE can be subjected to the PERC. This is a pre-test probability type situation, whereby you assess a patient based on clinical parameters (which you obviously already do!) but you mentally check them off a list of specific parameters, and if they meet all 8 (yes EIGHT!) criteria, then you can safely say they do not need further assessment RE:pulmonary embolism, D-dimers, CTPA route etc. This creates a warm and fuzzy feeling in me, because almost every patient in the past 3 years of practising emergency medicine in the UK that presents even remotely with pleuritic sounding chest pain, regardless of whether they have a clinical indication or not, automatically had a D-dimer, and, God forbid, should they have an ever-so-slightly-raised D-dimer level, they were referred to the acute medical team faster than you could say enoxaparin. These were then possibly unnecesarily given doses of enoxaparin, until the gold standard rule-out test could be performed, which is the CT PA (CT pulmonary angiography). That’s just the way things worked, because a positive D-dimer can indicated possible pulmonary embolism, but it needs to be taken with the complete clinical picture, and a (very large) grain of salt. D-dimers can, unfortunately or fortunately, be raised in a number of different situations, e.g an underlying active malignancy (which gives the double whammy of raising your chances of getting a PE in the first place), an infection anywhere in the body, certain medications and inflammatory medical conditions.  This lead to over treatment of many patients with anticoagulants till the CTPA was performed to finally confirm the existence or absence of the offending clot. Things may have changed for the better with the PERC, though.

The parameters you base your PERC score on are Age (< 50 years), O2 sats (greater than or equal to 95%), Heart Rate (less than 100 BPM), Absence of Hemoptysis, Absence of Oestrogen usage (Contraceptive pills), Absence of history of surgery/trauma requiring hospitalisation/immobilisation within past 4 weeks, Absence of lower limb swelling (unilateral), and absence of prior personal history of clots/emboli/thrombi.

These parameters and this score are widely used now and available as calculator/apps on most phones.

So the way I understand is, low-risk patients meeting the PERC score criteria need not be further assessed (even if they have had a D-dimer done that’s slightly raised, you can ignore it because the pre-test probability was extremely low). Low-risk patients not meeting the PERC criteria may then go on to be assessed on the D-dimer route, and the high risk patients go directly to CTPA without faffing around with PERCs and WELLS and GENEVAs.

Good luck, and happy PERC-ing!

Transfer Training

Attended a Transfer Training course today. I know what you’re thinking, who needs training to learn how to transfer a patient? What rocket science is involved in the few seconds or minutes to transfer someone from one bed to another? Or how much of preparation and thought needs to go into transferring a patient from one hospital to another? It has to be fairly simple right? Atleast thats what I was thinking when I was applying for the course, I thought it’s going to be like a 30 minute session, Bam Bam, thanK you, Ma’am type situation. Boy was I wrong – this was an 8 hour long proceedings, and I actually learnt quite a bit. Some gems from today’s talks:

Movement effects
Movement of any sort brings with it it’s own demerits. So only move the patient if absolutely necessary. Deceleration causes gastric contents to come up; it also may cause fluid to ‘back up into the lungs’.
Acceleration causes the opposite: hypotension, decreased preload. Both may lead to heart failure

Limit affects of any sort by making sure patient is well hydrated; lift the legs up to counter hypotension(during acceleration)

Head end up (15-30 degrees), NG (during deceleration)

Consider if you need Blue light? Is it time critical? Make sure to limit sudden movements, blue light ambulances are notorious for getting into accidents (large vehicles, moving at high speeds, sometimes against traffic and/or against traffic rules)

Specially important is the need to be careful in head and spinal injury patients
Contrary to popular belief and your gut feeling, the more critical the patient, the slower the transfer needs to be. Not faster. Fast, hasty movements make for bad decisions, wrong or sharp turns (as well as deleterious effects of movements already discussed)

Static effects
Hypothermia is the most common problem
What is the first thing that happens when patients are brought in to ED? Their clothes get taken off. Coupled with cold environment, not a good combo
Children/eldery most vulnerable
Monitor patient during the transfer as well for temperature changes; aim for normothermia
HME filter is one way to counter drop in temperatures – ventilator usually gives cold, not-too-moist air going directly into the lungs, bypassing the moistening and humidifying warmth of the sinus cavities; connecting an HME filter to the ventilator circuit effectively prevents the dry cold air going in, and thereby prevents hypothermia.
Blankets and foil may be used, especially in ambulances
Pre warmed fluids may be considered
Cover open wounds/burns (cling film is best as wound is still visible for any changes, is sterile essentially and can be airtight)

Avoid vibration injury/movememt in ambulance/helicopters
Pad and protect soft tissues to avoid pressure sores, and reduce fractures where possible. Ulnar nerve is most commonly injured during transfer – bean bag padding is ideal for such transfers.
Interference can be caused with electronic monitoring by the unnecessary vibration.movement aberrations from helicopters and ambulances; dislodged/trapped leads may also be a concern.

Motion sickness may develop – stop feeding the potential transfer patient. A couple of hours of NBM won’t kill the patient, but aspirating their own vomit, or vomiting when their neck is immobilised can be quite a significant clinical concern. Consider NG (with free drainage) and sitting upright. Avoid rear-facing seats for transferring teams. Do not read/documentation, as can make things worse. Be prepared. Take antiemetics.

Communication
Sirens/alarms make communication difficult. Make sure you can always hear alarms. And, we all are guilty of doing this, but NEVER ignore alarms.

Immobilisation
Need to ensure patient can undergo immobilisation. Make sure patient can actually physically lie flat for CT scans, etc (e.g. may get short of breath if massively obese or really bad CHF)
Consider sedation (and airway protective measures) if absolutely necessary to scan and lie flat.
Make sure you have everything you need before you leave. And before you need it. Always be prepared for every eventuality, every foreseeable complication.

Lying supine can also have other deletrious effects on even patient who can lie flat – secretions can accumulate, reflux might be an issue, V/Q mismatch occurs, inability to cough when lying flat, strapping someone down for a scan may itself cause restriction of lung movements in an otherwise comfortable-in-lying-flat patient.

NOBODY GETS BETTER DURING A TRANSFER! They may get worse, so only transfer if absolutely imperative.

Special considerations?
Trauma
general information about the Trauma network
ED pitstops – their pitfalls

Head/spinal injuries – RTC, falls, sports, assaults, self harm (gunshots), and non-traumatic
Motor aspect of GCS is more important than anything else in the GCS
Immobilise with correctly fitted collars
Aim for Normal pO2
Normal pCO2 is now the new teaching, as low PCO2 (which was previously the guidelines) causes cerebral vasoconstriction, reducing blood flow, and ischemia is a far worse complication than brain swelling, atleast in the initial phase of the post-injury timeframe.
aim for a MAP of 90 (this is ideal for cerebral perfusion pressures to be optimum)
Normoglycemia
Normothermia
Head up, minimize movements
Urgent Neurosurgical care
Maintain parameters at all times, even if the transfer is for short periods
Monitor pupil size, GCS, Heart rate/rhythm strip, blood pressure, pCO2, resp rate during transfer
Immobilisation and transfer methods were also touched upon, various methods to transfer patients, scoops, trolleys, mattresses, sliding sheets, boards etc
Consider Spinal shock if triad of hypotension+poikilothermia+bradycardia
Avoid fluiding with large volumes if unresponsive to fluids, consider escalating to vasopressors.
Will improve on own if spinal shock
Autonomic dysreflexia – injury above T6 (headache, flushing/sweating above level of injury, urinary retention)

Paeds

Rarely transferred. Only ever in cases of trauma/head injury
CATS
WETFLAG
Broselow tape bag
Vecuronium/pancuronium, fentanyl, ketamine (children) combo in children safe.effective cocktail

Balloon pumps- weigh 70 kg, slows movement, runs off battery

 

Another day, another training…

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
is anonymous,
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.
rapid cycle

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.

 

DIARRHOEA
definition
types
causes
symptoms
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

 

PALPITATIONS
multiple cases discussed and shown, along with rhythm strips, interactive 1 hour session with responses from the audience tailoring the talk. VERY interesting.

Advice that I wish I had when applying or even thinking about applying for EM training

Pre-alert! Boring post with an avalanche of information up ahead, kindly move on if not interested in EM as a future.

I was not always interested in EM. No, unsurprisingly, I used to be interested in surgery. I completed my medical school education in Pakistan, and actually did an elective placement in surgery at a Harvard hospital. WHILE in medical school. It doesn’t get any more committed than that.
Fast forward a few (read quite a few years!) and I found emergency medicine (or it found me, but that’s a story for another blog post – can’t put ALL my ideas in the same post now, can I? otherwise I am not going to have too much of a blog, right?). I did 3-4 years of emergency medicine as a non-training doctor back home in Pakistan, passed my PLAB exams which gave me a license to practise in the UK, and moved here to really try and get into a training post. I got into a non-training trust grade post as an ED SHO, and I have to admit, (credit where credit is due) my experiences in both the department of ED back home in Pakistan, and here where I started and got my bearings in this ED world, have quite a significant part to play in finally landing me this current training post I am in.

My advice to my peers and readers of this blog who are considering or might consider a future in EM to be their thing, is going to be severely bullet-pointed, for emphasis:

Start early. Prepare yourself. Arm yourself with as much information as possible about the program or specialty, about its general requirement and then its finer more intricate details. Look at the RCEM website, speak to college tutors and colleagues who are within the department, glean from them information about the various different pathways available, and what you need to do to get started, and also, of the many pathways available which one is best suited for your unique experiences and skill set.

– Pick a pathway that meets your requirements (or vice versa, you meeting its requirements, it’s all one happy marriage!) and set to work fulfilling the criteria for application. Now there are usually two sets of criteria for application to these posts: the mandatory, or absolutely necessary requirements, where if you apply with even one criteria missing from this list your application will go directly into a large waste bin the size of Suffolk that has accumulated many a CV since the olden days; and the lesser known and hence considered less important (but can be the difference between being offered an interview and going into the reject pile) preferable criteria, which aren’t mandatory, but if you have one or more of these, your application becomes a lot more likely to be considered over someone who say, has all the mandatory requirements but none of the additional preferred ones. Most important question? Where do you get this information. Ask around, read a blog (!) or google search ‘Person specifications for application to EM training‘ followed by the year when you will be applying, as they tweak the requirements every year. Look at the criteria now, and make a list of the things you have, and a list of things you still need to work on.

– Then decide on a timeline: is it achievable by application deadline this year? Ask yourself, is it really worth applying this time round with minimal criteria? Or can you look a bit better (atleast on paper!) next year and have a better chance? At any rate, if you have all of the mandatory criteria, it can not hurt to apply. If nothing else comes of it, then you can atleast consider it a learning experience, filling out the application and making yourself aware of the timescale and what needs to be done etc.

– Get a few things out of the way, as soon as possible. Get a National Insurance number, make sure you have at least 1 major course out of the way, ALS always helps, wherever you are applying, even if it is a non training course and I mean, come on, it should technically make you feel good about yourself and give you the confidence to handle a critical emergency, should it suddenly arise while you are let’s say standing in line at the Costa in the hospital and the woman in front of you collapses. Yes, ALS is definitely a plus to have on board, but do consider doing at least one other course – ATLS or APLS, or even the European versions of them – depending on availability, and your calendar of events for the rest of the year, your study leave and your budget. Never underestimate budget restrictions and always have that in the back of your mind. You can’t book an exam or a course or…do anything essentially if you can’t afford it. Also, make sure you are a member of medicolegal indemnity/insurance organisations like MDS or MDU.

Look at exam dates, if there is an exam requirement, make sure the exam requirement is met, atleast you should make an effort towards it (an honest effort, not just applying for an exam just so you can let someone know that yes I will be appearing for this exam, but I intend to party my free time away!) Factor in exam prep and study leave for an exam and travel and stay expenses if the exam is out of city, which it usually is. Also factor this in with your plans to participate in a course like ALS, ATLS etc, so that these don’t clash.

– Looking at the list of person specifications, you will notice that every requirement has an indication of when it is infact required by. So it will say, for example, that A is required by the time of application, and B is required by the time of interview, and C is required before the start of the program. So you can factor those elements in, and change the timeline of your requirements as needed.

Audit. Audit. Audit. Re-audit. It is so important, not just as a requirement for your application, but also for your GMC appraisal etc, and for your own growth as a physician, to participate in some form of quality improvement projects, from a minor audit to actual active research, anything that may serve to improve patient care from any aspect in the future. The topic of the audit can be relevant to your specialty, or a general one, or just any specialty actually, but what people tend to ignore is the fact that an audit is not just a tick-off-from-a-checklist-and-forget-about-it-now-that-I-am-done thing, but you should create a timeline where you spread the findings from your audit like the joy it will bring (it will not) to everyone concerned, for example your department staff, and let them know how to improve things. Keep reiterating the how-to-improve-things and keep reminding them till you achieve a little things-have-improved situation. THEN YOU RE-AUDIT THE WHOLE THING AGAIN, after a certain time period to allow for improvement, see if there is any improvement. You could re-audit it again, and again. Interviewers and the people considering your application want to see commitment to a goal, and what better way to show commitment than to keep trying to address an issue that you think is a problem and can be improved. Speak to your supervisor or any consultants, they will be glad to receive some help in some ongoing audit or you could give an idea for an audit of your own.

Get started on an e-portfolio, and started getting any and all competencies signed off as early as possible. What you do matters, and make every bit count. If you have intubated 500 patients, but can not provide any documentary proof of it, then you will be second to the person who can show signed competences of having done even 25 intubations. MAKE EVERYTHING COUNT. Read more about this here.

While this is in no way an exhaustive list – it is still a work in progress and I have still got so much to learn – but I do feel that this list forms the basis for entering into any training post, not just emergency medicine. You could embellish your CV in any way to make it better suited to a certain specialty – but these particular little things form the crux of any training application.
In the end, I would like to add a forgotten little adage: “Anything worth doing, is worth doing right.”
So make sure you do it right. Good luck!”

 

(WATCH THIS SPACE FOR MORE POINTERS, I WILL COME BACK AND EDIT THIS AND ADD SOME MORE THINGS.  THIS IS AS MUCH AS I COULD TYPE FOR NOW, DADDY DUTY CALLS. MY SON IS TRYING TO TYPE onNTHELaptopsh and canhtwriteakh anyFURTHer862mx..