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Ubuntu #3: The Michelin Man: The case of a ruptured bulla

 992 757 Kat Evans

Ubuntu #3 The Michelin Man: The case of a ruptured bulla

Author: Dr Kylen Swartzberg | Editor: Dr Kat Evans

The Case: Presented in real time
Friday Night, Ubuntu Emergency Department.

Untitled Infographic (1)21:15 – 53 year old male patient rushed into triage in a wheelchair by his panic stricken wife. She shouts to the triage nurse that her husband’s lips & face started swelling up 10 minutes ago whilst at a braai & states he is allergic to Penicillin.
Two ED doctors happen to be walking past during the exchange & notice the swollen face & air-hungry patient. They grab the wheel chair & rush into the resus bay activating the resus alarm.

21:16 – Whilst one doctor & nurse move the 100Kg looking patient onto the bed & start face mask O2, the other doctor administers 0.5mg adrenaline IM in the right thigh. The next dose is drawn up & kept aside.

21:17 – Further colleagues have arrived & lines are prepared. The patient is only able to speak 2 words per breath. The first line is up in the right cubital fossa & hydrocortisone & promethazine are given IV.

21:18 – Monitors are being connected & whilst the 2nd IV line is being inserted, one of the doctors exclaims that there is a lot of crepitus in the arm & hand. The doctor speaking to the patient & adjusting the face mask also notices that there is diffuse crepitus of the entire face & scalp.

21:19 – The senior doctor asks the patient if he smokes? With a deep breath & a raspy voice he says ‘yes’. The senior excitedly proclaims that she knows what this is & that she has seen this once before…..

21:20 – Whilst the BP cuff is inflating the seconds of suspense feel like a TV game show taking an ad break. “It’s a ruptured bulla!” There is a brief sigh of relief as anaphylaxis is shifted off the working diagnosis. The vitals monitor beeps in 200/110. (Due to the IM adrenalin & subcutaneous emphysema) Saturation on non-rebreather mask is 92%.

21:21 –  The senior directs preparation for a definitive airway due to extensive upper airway & neck subcutaneous oedema as well as bilateral IC drains. (Xrays will take too long & due to diffuse subcutaneous emphysema, from scalp to inguinal ligaments, ultrasound lung evaluation is not currently of use).

21:23 – The patient reports worsening difficulty in breathing. Induction agent & muscle relaxant given.

21:24 – A difficult airway is anticipated. The most senior doctor is ready with laryngoscope in hand. Video laryngoscopy is at the bed side as backup. ET tube goes in, in seconds. The team member who assisted with external laryngeal manipulation keeps his finger on carotid pulse.

21:25 – No pulse is felt. A wide eyed medical student begins chest compressions. Bilateral finger thorocostomies are done simultaneously by a doctor on each side. Air gushes out of the right thorocostomy incision. The first paddle check is done after about 15 seconds of compressions & completion of thorocostomies. An organized rhythm & a palpable central pulse.

21:26 – The now haemodynamically stable patient is seated at 45 degrees. X-rays are on the way, the medical team is notified to prepare an ICU bed. Excitement & team high fives all around.

21:45 – The patient looks 20Kg lighter & his face looks like he is a different person as the subcutaneous emphysema rapidly begins to decompress. “He is beginning to deflate” are the words used on the handover round by the doctor who affectionately dubs this patient ‘The Michelin Man’.

michelin man

Outcome:

The patient is extubated in ICU during the early hours of the morning & found later that day to be eating a meal. He is only identifiable as he is the only patient in the general medical ward with bilateral chest drains. His face looks entirely different as he has now fully ‘deflated’. He reports feeling great except for having a very painful chest.

Discussion & Learning points:

Bullous lung disease is a spectrum of disease with multiple causes, most commonly smoking 1,2

Patients with bullous emphysema, especially large bullae are at higher risk for pneumothorax 1,3

There are numerous case reports in the literature of ruptured bullous lung disease. So this is definitely a topic to keep in mind when patients with a smoking history or emphysema present with shortness of breath & chest pain.

In this case it was a very different presentation to which normally is the case & given the very brief history of known allergy & facial swelling & breathing difficultly, the possibility of this being anaphylaxis was real & it was a good move to start treatment for it. Besides the increased BP, no obvious harm was done in the process. Possibly an earlier history could have been gained from the wife regarding other conditions & habits.

Always touch your patient. How important was this in this case? The doctor verbalizing to the team what he was feeling was key to triggering the memory of the senior who had just walked in & had not yet had the opportunity to touch the patient.

This leads on to the need for good & clear communication between team members & team leader during a resuscitation. One doctor can not be doing, feeling & seeing everything at once so good communication is vital.

The case also highlights that there are no shortcuts to experience. In other disciplines there can be a monotony of cases but this is obviously not the case in emergency medicine. This forms a major component of why many of us love EM. It may take years to see or experience a specific condition & when that happens, take stock of it, read up about it, take it in & store it. You never know when your single experience will save the life of the next patient or help others learn. There is a dictum that I always rely on: “no effort is wasted”. Even if there are at present no obvious results or rewards, the time will come when the effort pays off.

This case also demonstrates how absolutely crucial it is for the entire team to be engaged. Every one doing their part to make the whole come together. All aspects of the resus were happening in parallel. Oxygen, lines, drug prep, IC drain prep. As well as anticipating the course of disease/events. The anticipation of the possibility of airway compromise, the possibility of the airway being difficult, the anticipation that when PPV was started IC drains were not yet ready, so staff at the ready to perform finger thoracostomies.

Things can escalate rapidly here in the ED of the Ubuntu hospital and when working as a team, lives are saved on a daily basis.

Edited by: Dr Kat Evans

Author: Dr Kylen Swartzberg

Emergency Medicine Registrar – Johannesburg, South Africa

Passion for all things emergency medicine, teaching & sharing of knowledge.

A love for the outdoors and scuba diving.

  • Kat Evans

Ubuntu #2: Divination and a Diagnostic Dilemma

 2058 1500 Victoria Stephen

Ubuntu #2: Divination and a Diagnostic Dilemma

Author Victoria Stephen

Edited by Kirsten Kingma

 

You are on duty at uBuntu Hospital Emergency Department on a Tuesday evening when a 37 year old male is brought in by EMS. His neighbour had called EMS when she had noticed that he had not ventured out of his house all day. She doesn’t know his medical history but she is aware that he hasn’t been feeling well over the past week. Paramedics found him in bed, unconscious. His vital signs from triage are: blood pressure 115/66, heart rate 121 BPM, respiratory rate 28 breaths per minute, Sats 82% in room air, temperature 39.2 C and his finger stick glucose is 7.2 mmol/l.

The nurse puts him on face mask oxygen and IV fluids are started. He is unconscious and responds only to pain with no obvious focal neurological deficits. You identify his GCS as E2V2M3 = 7/15. His pupils are sluggish. His chest is difficult to auscultate due to transmitted sounds from his upper airways, but breath sounds are reduced on the right. After intubating him and getting him settled on the ventilator, you examine him more thoroughly.

He appears slightly wasted and has generalised lymphadenopathy, but what catches your eye are multiple small superficial lacerations over the 6th intercostal space of his anterior chest. What do they mean? Could they point towards a possible diagnosis?

vic1

 

Overview

These incisions are scarification marks; known as “izingcabo” in isiZulu, which is one of South Africa’s 11 official languages. They are made by traditional healers when patients consult them for their various illnesses and concerns. Traditional medicine is rubbed into the freshly made incisions in order to try cure the ailment the patient is suffering from. The contents of traditional medicine vary but usually consist of herbs, bark, leaves and minerals. Traditional healers are common in South Africa, with 60- 80% of the population consulting them for various illnesses and social problems. Patients frequently will consult a traditional healer in their community before seeking medical attention, especially in rural areas where hospitals and clinics are few and far between.

 

There are different categories of traditional healers in South Africa, the most common being herbalists (inyangas) and diviners (sangomas). Herbalists dispense traditional medicine made of plants, inorganic substances and occasionally animal extracts. Diviners believe that they can discern the cause of a patient’s illness by speaking to the patient’s ancestral spirits.
Scarification marks are usually made with razor blades. They are commonly made at the site of the patient’s pain, or over a swelling, such as over oedematous feet. They may be seen over the left hypochondrium if splenomegaly is present. In cases of sciatica , they may follow a dermatomal distribution. They are also made over the back of the neck, on the sternum, or around the umbilicus when a patient desires protection from illness or harm. Scarification sites can become infected particularly if traditional medicine is applied in the wounds, so they should be carefully inspected.

 

You pick up the ultrasound probe and out of curiosity you scan over scarification site, and this is what you see:

vic2

An abdominal ultrasound image of the right upper quadrant in the longitudinal plane: The liver is seen on the right of the screen. A densely consolidated lower lobe of the right lung is seen on the left.

 

This patient had community acquired pneumonia, which was complicated by meningitis. He had consulted a traditional healer after he had fallen ill. It may be that he had reported right sided pleuritic chest pain to the sangoma who then made the scarifications in an attempt to cure him. It is useful for medical doctors to know what scarifications signify as their presence can offer clues to a diagnosis. It’s also important to be aware of the cultural beliefs our patients may have and to educate them as much as possible about the aetiology of their illness.

 

Untitled Infographic



 

Further reading:

Traditional healers and paediatric care. De Villiers FPR, Ledwaba MJP. SAMJ 2003;93:664-665

Treatment received by children who visit traditional healers. Ayibor PK Research Resport MMed (Paediatrics) University of the Witwatersrand 2008. Accessed from: http:www.wiredspace.wits.ac.za/bitstream/handle/10539/7466/Research%20Prosper%20final.pdf

Metallic Mercury use by South African traditional health practitioners:perceptions and practices Environmental Health 2015:14;67

Acute lower back pain mapped by dermatomal scarification in urban Malawi. BMJ case reports 2012 doi:10.1136/bcr-11-2010-3529

Splenic enlargement and abdominal scarifications in childhood malaria: beliefs, practices and their possible roles in management as seen in Benin City, Nigeria. Niger Postgrad Med J 2008:15;70-5

  • Victoria Stephen

Ubuntu #1: Not another tachypnoeic pregnant patient!

 1470 827 Kat Evans

Ubuntu #1: Not another tachypnoeic pregnant patient!

Guest Author: Dr Neville Vlok | Editor: Dr Katya Evans

History

  • Mrs V is a 35 year old G3P2 female at 32 weeks pregnant by dates. She was referred to Ubuntu hospital for IVI antibiotics after being seen at the local clinic with a diagnosis of “severe pneumonia”.
  • Complaints: dyspnoea & cough x 10 days – already receiving her second course of oral antibiotics.
  • Background: she admits that she is sharing not only cigarettes, but also illicit smoked drugs (methamphetamines) with someone that has active pulmonary tuberculosis. Previous encounters with healthcare services included 2 previous uncomplicated vaginal deliveries & a stab wound to the left chest which required an intercostal-drain.

Examination

SaO2 95% | BP  96/56mmHg | HR 119bpm | Temp 36*C | RR 25bpm
Whilst looking at Mrs V you notice that personal hygiene is poor, she appears acutely ill and significantly distressed.
“Not another substance-abusing woman in labour” you think whilst the melody of moans, groans & monitor-alarm overtones fill the hospital.
  • Obstetric & abdominal exam: non-significant with the uterus size corresponding with the 32 weeks given as history.
  • Resp exam: decreased air entry in the lower left zone
  • CVS: low-output status is suspected – pulse is noted to be of low volume, rapid with cool peripheries & soft cardiac tones. Jugular veins are distended
  • Calves: soft, which is reassuring

Investigations:

Chest X-ray

Note: Globular heart with increased cardio-thoracic ratio. (Also note: X-ray being held up against window in true Ubuntu Hospital style due to lack of functional X-ray viewing box / electronic X-rays.. gives clue as to developing world location of patient..)

CXR

12 Lead ECG

Notice the electrical alternans in V2, attributed the heart swinging around in the pericardium.
ECG

Point of care ultrasound

You grab the ultrasound & start scanning for any clues that might help. You expected a large, dilated, obstructed right heart, because pulmonary embolism just seems to be the obvious diagnosis. You don’t see any pulmonary pathology or even a small pleural effusion you were hoping for. You do a quick subcostal view to look at the heart and pericardium and see this surprising finding.

Management

Yes! You diagnose your first cardiac tamponade at Ubuntu hospital and with a quick, perfectly placed stab of a largebore-needle under ultrasound guidance another life is saved in Ubuntu Hospital!!!

Diagnosis

Outcome

  • After pericardiocentesis – admitted to the obstetric highcare unit for cardiovascular & fetal monitoring.
  • Diagnosis of HIV infection was made with a CD4 count of +/-500 & high viral load.
  • Whilst awaiting culture & biochemistry of pericardial fluid she was started on standard 4-drug TB regimen as well as 10mg Prednisone on advice of the cardiologists.
  • Day 4: Her stay was uncomplicated & she spontaneously went into labour, she delivered a healthy female infant via C-section with no complications.
  • Day 6: discharged from the highcare to the ward.
  • She was kept for another 14/7 of observation in the medical-obstetric ward, discharged with no recurrence of the tamponade, only a small residual uncomplicated effusion.
  • 3 sets of sputum were negative for TB (?poor technique/non productive cough), as well as TB culture from the pericardial fluid. Cytology revealed scanty atypical cells of uncertain origin. Thus the diagnosis of TB not microbiologically proven, but favourable response on anti-tuberculous treatment prompted a 9 month course of TB treatment.
Dr Neville Vlok
2nd year intern in Johannesburg.
Budding critical care physician
Other interests: prehospital emergency medicine, PoCUS, photography, travel & a good bottle of red wine.
  • Kat Evans

“How to get brave: The three steps for implementing change” with Almero Oosthuizen

 3000 1714 Jo Park-Ross

Podcast: Jo Park-Ross and Almero Oosthuizen

Are you keen for change? Not sure how to be part of the change you think is needed?

Here is a short podcast to motivate you!

The three steps to implementing change:

1. Win them over

Create your brand, cultivate genuine relationships, understand the problem fully and connect with people who are like-minded in fueling change.

2. Set yourself up to win

Propose a pilot: this is your one good chance so be sure to do it properly!

3. Get BRAVE!

This is just the beginning, relish the challenge!

 

 

 

 

 

Cover photo of fire in a Cape Town informal settlement. Photo by Matthew Rosenberg.

  • Jo Park-Ross

Balancing chakras – the passive leg raise

 1075 700 Kat Evans

Balancing Chakras: The passive leg raise

Author & Sketches: Dr Serena Cardosa | Edited by: Dr Kat Evans

Yog

As a medstudent, the topic of fluids eluded me.  When I started working as a junior doctor in the EC this year I had to gain confidence with my fluid resuscitation strategy (and fast!). In this post I will attempt to introduce a simple approach to the basic (albeit challenging) question surrounding fluid resus:

“Does this unstable patient need IV fluids?”

Why do we give a critically ill/septic patient fluids?

The thinking goes: if you fill said patient’s tank you may improve organ perfusion and optimize oxygen delivery & cellular metabolism. By doing this, you may improve the patient’s condition.

We know that only 50% of haemodynamically unstable patients respond to fluids. We also know that sometimes fluids can be harmful, with the potential of causing pulmonary oedema, inflammation, acid/base problems and even increased mortality. One study published in the BMJ, the FEAST trial, found that fluid boluses significantly increased 48-hour mortality in critically ill African children with impaired perfusion. Other studies like the SOAP study demonstrated this too.

So how do we know whether we should give our patients fluids? The answer is found in another question:

Is the patient fluid responsive?  

Remember the Frank Starling principle?

frank starling

Above is the Starling Curve. Imagine the heart is made of elastic bands. When we give a fluid bolus to the heart there is lengthening of the cardiac cells (sarcomeres) during diastole (preload) which results in greater ‘snap-back’/contractility of the heart and a greater volume of blood ejected during systole (cardiac output).

There is a point where the fibrils reach their optimal contractility, and beyond that no amount of fluids/stretching will result in increased cardiac output.

Like an elastic band that you’ve stretched too far, they just don’t bounce back like they used to (i.e. congestive heart failure) in fact they can break.

 Give fluids to ‘fluid responders’

Before we give fluids we want to know if they’re still on the ascending limb of the Starling Curve, where a fluid bolus will result in increased cardiac output/ SV (preload responsive).

frank staling reserve

So how do we tell where on the curve the patient is? Every patient has their own unique Starling Curve. This is why static measures of volume responsiveness like blood pressure, low urine output and CVP measurements only suggest that the patient may be volume depleted. As we don’t know where the patient is on the curve, these single static indices won’t indicate if they are going to be ‘fluid responders’.

That’s why we need something more dynamic to show us how much preload reserve we’ve got. Dynamic measures also look at the interaction between the cardiac and pulmonary systems.

Passive Leg Raise

The passive leg raise (PLR) works in the same way, but instead of giving a potentially detrimental fluid bolus you utilise the blood that had pooled in the legs & splanchnic system as your preload.  It is a diagnostic test, not a treatment modality. It should be performed utilising a cardiac output monitor or arterial line tracing, however in the Ubuntu Hospital setting, non-invasive blood pressure recording used as a surrogate is often the only option.

Benefits:

  • reversible
  • non-invasive
  • easy
  • can be repeated many times without harm.
PLR illustration

Have the patient sitting up on a bed at 45 degrees. Note the MAP. Lower the head of the bed to horizontal & passively raise the legs up to 45 degrees. At 30-90 sec repeat the BP. If the patient is fluid responsive the approximate 300ml bonus you’ve recruited from the legs & abdomen will result in a MAP increase of 10%. Position the patient back and notice reciprocal change.

Basics:

MAP increases >10% with PLR – Patient will likely respond to IV fluid = “Fluid responsive”

MAP does not increase with PLR (or decreases) – Patient will likely NOT respond to IV fluid and may need vasopressors = “Not Fluid responsive”

 

Problems:

  • unreliable in patients with raised intra-abdominal pressure or are severely hypovolaemic (where there isn’t even enough volume in the legs to create a preload bolus)
  • you will have to stop other interventions whilst you do this
  • patients where positional changes are contra-indicated.

Web References

About Dr Serena Cardoso:

 Doctor working in her ‘Community Service Year*’ at a Cape Town Emergency Centre. 

Learning to love Emergency Medicine!

* ‘Community Service Year’ is a 1 year government hospital employment that is required to be completed in South Africa following internship years. Doctors work as independent practitioners & at many areas are the only doctor on duty in an Emergency Centre – this results in a extremely steep learning curve!

  • Kat Evans

Finding FOAM

 1173 714 Kirsten Kingma

This week I did a talk at the Hout Bay Volunteer EMS about how to get involved with FOAM for the beginner (with a focus on prehospital FOAM).

If you are new to the FOAM world and want to know how to get involved and what it is all about then this for you!

 

I recommend the following links for further reading and to get the process started!

Screen Shot 2015-08-27 at 8.42.09 PMScreen Shot 2015-08-27 at 8.42.34 PM

The blogs I mention

  • Please check out our list of local FOAMed resources to follow!
  • PHARM – prehospital and retrieval medicine
  • St. Emlyn’s – excellent emergency medicine blog posts that give insight into specific topics
  • EMCrit – Scott gives some of the best podcasts around, excellent talks and resources on his site
  • Taming the SRU – they have a special page dedicated to posts on prehospital medicine
  • Excellent podcasts by the best speakers in emergency medicine on a wide range of topics: check out SMACC (for iTunes podcasts click here)

 

 

The link to the Prezi presentation given at HBVEMS

 

And the screencast of the presentation (during the actual presentation I enjoying a Guinness so Im sure that was far more entertaining)

  • Kirsten Kingma

The Namibian Pre-hospital System

 4358 2083 Jo Park-Ross

The Namibian Pre-hospital System

Guest Author: Nadine Seymour & Edited by: Jo Park-Ross

                                  Friehauf_Namibia_mapNamibia_map

Pre-hospital Emergency System in Namibia

Namibia lies in Southwest Africa; it is largely and sparsely populated with vast distances.  Windhoek, the capital, is the largest city & is found almost in the centre of Namibia, surrounded by mountains.  Namibia’s health system is mainly state run, providing health care to the majority of the population.  Currently there is a ratio of 1 nurse per 500 people; 1 doctor per 4000 people & 1 emergency care practitioner per 7000 people.  Windhoek has 3 privately run hospitals & 2 state hospitals.  Each of the major towns surrounding Windhoek have state hospitals with the smaller towns, villages & rural settlements serviced by clinics & health centres, these are all operated through the Ministry of Health & Social Services (MoHSS).

 20150819_101520

EMS Services

Pre-hospital emergency care services are vastly spread throughout Namibia with the majority of pre-hospital practitioners being found in Windhoek since around the late 1990’s.  There are to date a number of private ambulance services which are comparable to 1st world countries, 2 of which are capable of providing evacuation & transportation by fixed wing & 1 by rotor wing, with the occasional use of the Namibian Police helicopter when required.  The 2 state run ambulance services found in Namibia are provided by the MoHSS & City of Windhoek Emergency Management Division.  The MoHSS ambulance service still uses Basic Life Support (BLS) & some Intermediate Life Support (ILS) practitioners to drive the ambulances while nurses provide treatment to the patients.  The private & state EMS services mainly provide basic (BLS) & intermediate life-support (ILS), with very few advanced life-support (ALS) practitioners registered & working in Namibia.

EMS Practitioners & Training

Currently there are around 35 registered ALS practitioners with even fewer of them actually practising in Namibia.  The scope of practise for BLS, ILS, ECT & ALS was fashioned on the South African Health Professions Council protocols & scope of practice.  The protocols for BLS, ILS, ECT & ALS have been re-addressed to focus on the needs & resources of Namibia; however these are still waiting to be accepted by the Health Professions Council of Namibia (HPCNA).

Training in Namibia is very similar to that of South Africa.  There are private & state institutions that provide BLS & ILS short course training; however there are no short course ALS training facilities in the country.  The Polytechnic of Namibia, which has now transformed into the Namibia University of Science and Technology (NUST), is the only institution that provides tertiary training in Pre-hospital Emergency Medical Care.  This programme was established with help of the Motor Vehicle (MVA) Fund of Namibia back in 2009 & to date we still endeavour to work closely with each other.

The programme provides a Bachelor’s degree in Pre-hospital Emergency Medical Care (NQF 7) & covers aspects similar to that of South African institutions, including that of Rapid Sequence Intubation (RSI), this enables registration with the HPCNA as an advanced life-support (ALS) practitioner.  The course however only provides a Basic Medical Rescue course as part of the qualification; which includes light-motor vehicle extrication, basic fire rescue, high-angle 1 & hazardous materials awareness.  The qualification also allows students to exit after the second year with a Diploma (NQF 6) in Pre-hospital Emergency Medical Care enabling them to register with the HPCNA as Emergency Care Technicians (ECT).  Most of these ECT’s that have qualified have already been absorbed into private, parastatals & the surrounding mining industry to provide medical care to workers on site.

EMS has additional assistance from the City of Windhoek Emergency Management Division who also provides a rescue service to the community.  There is no officially established rescue outfit in Namibia & therefore all services rely on the City of Windhoek to assist where needed.

Screenshot_2015-08-15-21-42-35

Transportation

Patients are transported via ground ambulances within Windhoek & the closer surroundings; however fixed wing aircrafts are often used due to the vast distances outside of Windhoek to the northern & southern areas of Namibia as well as outside the country.  Occasionally rotorwing aircraft are used for rescue scenarios in & around Namibia.

Challenges

Although these areas have access to BLS & minimal ILS, there are few to no ALS practitioners available outside of Windhoek.  This makes for increased response times due to the vast distances.  This is further compounded by the under-resourced areas, limited ALS qualified practitioners & poor socioeconomic conditions.

Opportunities in the Making

The EMS system is still very young & therefore great opportunity lies within EMS itself to have an African system that caters to Namibian needs.

The Namibian Emergency Care Practitioners Association (NECPA) has recently been established to bring together EMS practitioners, industry & the HPCNA in order to drive the profession into the future.

Links to a few websites:

www.polytechnic.edu.na   or Find us on Facebook: Polytechnic of Namibia EMC

www.necpa.com.na

www.ata-international.com.na

www.emtss.com

www.mvafund.com

  • Jo Park-Ross

Continuous Professional Development in South Africa

 300 290 Craig Wylie

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As healthcare professionals we all have the responsibility to stay up to date with current practices & advancement within our respective medical disciplines. In South Africa the Health Professions Council of South Africa (HPCSA) requires healthcare professionals to accumulate a total of 60 continuous educational unit (CEU) points over a 2 year period, of which 10 CEU points should be related to ethics. There are some sub-categories that require less points, such as basic ambulance assistants that are only required to obtain 30 CEUs over a 2 year period.

The HPCSA reserves the right to implement mandatory audits on practitioners registered with the board. Once a practitioner is selected he/she has 21 days to submit a summary of points accumulated over the period in question. Failure to provide the summary will lead to a grace period after which the board can take action against the practitioner in question.

So the question on every practitioners mind should be: ‘how do I achieve the 60 CEU points?’

Types of CEUs in the South African setting:

Level 1

These meetings have no measurable outcomes and are allocated CEUs according to time. Most often these activities include:

  • Presentations
  • Organisational meetings
  • Case Study discussions
  • Structured, registered teaching ward rounds
  • Conferences

Participants normally receive 1 CEU for every hour attendance at these events & presenters can receive 2 CEUs. The maximum amount of CEUs per day is 8.

Level 2

These activities include education, training, research & publications with measurable outcomes, but does not constitute a full year of earned CEUs. These can include, but are not limited to:

  • Peer reviewed publications or books.
  • Being a reviewer of an article.
  • Presentation at a conference.
  • Presenting a short course
  • Examination of Masters or Doctoral thesis
  • Professional interest groups

CEUs are allocated as per a matrix which is published on the HPCSA website.

Level 3

This level includes formal learning activities that are accredited with the HPCSA & have measurable outcomes.

These include under-graduate and post-graduate degrees. (eg; MBCHB, Bachelors Degree in Emergency Medical Care)

Normally successful completion of a year of study would earn you 30 CEUs.

So, how do we get these points?

CPD activities are normally well attended if word gets out!

We will be posting regular updates on our blog events page regarding CPD activities in South Africa, both free & paid. We invite any & all conveners to get in touch with the badEM crew & inform us of your activities. Email us at info@badem.co.za

REMEMBER: As healthcare professionals you are responsible to keep yourself up-to-date.

We invite our colleagues from around Africa to provide us input/perspective on their rules & regulations regarding continuous professional development, so we can expand on this post.

  • Craig Wylie

Ubuntu Hospital – African Virtual Hospital, Aeromedical & Ambulance Service

 1024 544 badEM

Ubuntu Hospital & Ubuntu Aeromedical & Ambulance Service

After much deliberation we decided not to ask for admitting privileges at St Emlyns (UK) or JANUS General (US) Imaginary Hospitals, but rather open an African virtual hospital.

crush

We felt that the developing world has it’s own specific set of unique problems that can only be expressed adequately in an African environment! Problems including Sjambok injuries causing Crush Syndrome, PERC negative & Wells Score of zero not equating to no DVT/PE in the HIV/TB setting, Cape Cobras, Cable thieves buried underground for >24hours, commonplace >20 intercostal drains on a Saturday night at a primary healthcare clinic, ‘Tik‘, Anti-Retroviral & TB Medication Overdoses, Minimal access to PCI (and in some places no access to Thrombolytics), TB/HIV overwhelm units.

 

All practitioners across Africa are welcome to “admit” patients to our imaginary hospital or utilize our EMS services to transport patients. The Ubuntu group name is available to maintain patient confidentiality to allow discussions of patient cases for educational benefit. Basically there are minimal rules as it is an imaginary hospital/service!

 

They way it works is just email us your interesting case, or case in which you learnt something (can be a medical or non-medical learning point!) We will then look through it & help you to turn it into a badEM guest blog post – this can either be done anonymously or with your name attached.. Send to: info@badem.co.za & we can discuss further.

 

If you would like to know the origin of the name ‘Ubuntu’ that our hospital is named after please read more here.

banner TB

(Written consent for use of photographs online obtained from patient pictured in image)

  • badEM

Under pressure: Endotracheal tube cuffs

 1267 570 Jo Park-Ross

What’s the problem?

The average internal diameter of an adult trachea is 1,5 – 2 cm and this doesn’t leave much room for expansion. Over-inflated cuffs could be killing off tracheal mucosa by restricting blood flow, causing problems such as tracheal stenosis: a long term condition which will need a multi-disciplinary team and some expensive surgery to fix, if it is fixable. This is money we shouldn’t be wasting, and avoidable morbidity we could be sparing our patients.

There are 3 commonly used clinical methods for inflating cuffs:

1. Palpation: Inflate cuff with air. Feel cuff between fingers. Decide the cuff feels right.

2. Pre-determined volume: Inflate cuff with pre-determined amount of air (10ml,15ml,20ml?).

3. Minimal leak: Inflate cuff. Listen for air leak during ventilation. Decide the leak is ‘minimal’.

It was demonstrated in multiple studies that even anaesthetists in theatre (whether experienced or not) were not able to achieve acceptable pressure range using clinical methods alone. Working in the out-of-hospital sphere or the emergency centre, we do not have the luxury of a quiet working environment so these methods are likely even less reliable in our environment. On top of this, a cuff inflated to pressures within the ‘safe zone’ feels a lot softer than I expected, and used less air than I had been taught to use.

Gold Standard = Cuff Pressure Manometer

 

What are we aiming for?

Screen Shot 2015-07-29 at 11.18.21 PM

Screen Shot 2015-07-29 at 11.14.29 PM

Visual demonstration of air-filled cuff pressure in flight:

A 50ml syringe to simulate the internal diameter of an adult trachea (it has a 3cm internal diameter, which is larger than an adult trachea). The manual cuff pressure manometer was attached to air filled ETT cuff via the extension set.

 

1. Before take off:

Cuff inflated to within safe limits.

1. Aircraft on ground

 

2. Half way through our climb to altitude (Cabin altitude 3770 ft)

Cuff pressure is already well outside of safe limits.

climbing_final skitch

 

3. Cruising altitude (cabin altitude 6470 ft)

Cuff pressure is almost 3 times the safe upper limit.

3__At_altitude_-_6470_ft

 

4. Reset the cuff pressure to within safe limits at cruising altitude

(cabin altitude 6470 ft)

4__Reset_at_altitude

5. Half way on the descent (cabin altitude 3230 ft)

Cuff is well below the low pressure limit – potential for aspiration increased

5__descending_after_reset_at_altitude

Saline for aeromedical transfers?

So, you’ve been told replacing the air with saline is second best. There are a few reasons why this isn’t true.

1. This is not what an ETT cuff is designed for or the approved usage as tested by the manufacturer

2. It is impossible to remove all of the air and replace it with saline, so there will be expansion (and increased pressure on the mucosa) with even a small increase  in altitude. I have tried this personally over and over in a simulated airway, and there is always a residual bubble.

3. Once the cuff is full of saline, you can no longer measure the pressure: if you cannot guarantee the pressure the cuff is exerting on your mucosa, as you cannot measure the pressure then why do it?

4. The exchange itself: despite your best effort with your faithful suction, there will be some aspiration of secretions that have likely sat around the tube for as long as your patient has been intubated. Are you willing to expose your patients to this unnecessary aspiration? There is also a possible risk for adverse events such as accidental extubation or right main bronchus intubation if the procedure is not well controlled.

5. That tube will be most likely be exchanged as the ICU won’t keep water in the cuff: this exposes the patient to risk of an adverse event such as aspiration.

So please, in ALL of your intubated patients – remember the cuff.

 

 

Want to read more?

A little more about air transport of the critically ill

Some South African literature on the subject:

http://t.co/iF4vfdwDsr

http://www.samj.org.za/…/samj/article/download/4469/3124

 

 

  • Jo Park-Ross