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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

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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!

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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

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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).

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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.

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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

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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?

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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

Sonar beams deflecting cognitive error

 723 641 Kirsten Kingma

Sonar beams deflecting cognitive error

Osler

Written by guest author: Victoria Stephen

In the midst of treating a critically ill patient, whether it is pre-hospital, in the ED or ICU, time is not on your side. Multiple processes are taking place concurrently, as you take in the history, the patient’s appearance and vital signs. Your mind is rapidly assimilating the information, attempting to piece together the underlying condition and how to treat it. The pressure is on to recognise the problem and to treat it effectively while preventing harm, a situation which is fraught with the potential for cognitive error.

 

Cognitive error and diagnostic reasoning came up time and time again at the recent amazing #smaccUS conference in Chicago. Simon Carley spoke of clinical gestalt, that gut feeling we get when treating a patient, how often are we correct? Louise Cullen and Ric Body discussed gestalt in the diagnosis of chest pain, and showed us that gestalt (gut feeling) is as good as flipping a coin, being correct only about 50% of the time. Tim Leeuwenberg gave a powerful talk on diagnostic error and its effects on our emotional well-being. Pat Crosskerry, known for his ground breaking work on cognitive processing and error in Emergency Medicine, reminded us of how fallible our thinking is, and though system 1 thinking is useful in our time-limited high risk speciality, it is fraught with potential for error. Scott Weingart gave an interesting talk on OODA loops, a form of system 1 thinking that can be used by experts to rapidly adapt to the dynamic time critical nature of resuscitation. Make sure that you get to listen to all these fantastic talks through the smacc podcasts that will be available later in the year.

 

It’s all very well to be aware of diagnostic reasoning and cognitive error as we treat critically ill patients. How do we translate theory into practice? Scott Weingart’s talk on OODA loops was fantastic, but how does a trainee gradually negotiate these loops? How do we reduce our risk cognitive error and its potential effect of harm on our patients when time for decision making is limited?

There are many strategies, but one will be the focus of this post – the use of point-of-care ultrasound.

A case in point:

I was on duty on one particular busy winter’s night a year or two ago. It was 4 am; I was exhausted, having been in resus for 8 hours already. The patients had been critically ill and challenging. Just as the ED had appeared to slow down, a 35 year old female was wheeled in. She was exceptionally breathless and couldn’t complete sentences. To make the situation more difficult, she spoke Shangaan, a language which neither the nurses nor I could speak. All that could be gleaned from her was that she was HIV positive but did not know her CD4 count. She had been sick for a few days with haemoptysis and dyspnoea. That was it.

She was diaphoretic, tachypnoeic at 48 breaths per min and her sats were 61% on a non-rebreather mask. Her initial BP was 130/90, pulse 110 BPM. She was coughing up pink sputum.

A quick exam was done while monitors were placed and an IV inserted. She looked like many of the patients I had already treated that evening: wasted, pale, oral thrush – stigmata of HIV. Chest: coarse crackles bilaterally. CVS: loud P2. I couldn’t hear a murmur, the chest was roaring with crackles around the background din of the ED.

I assumed the diagnosis with little further consideration, neurons only capable of firing away in bullet points: HIV, low CD4 count, likely multi-lobar pneumonia with ARDS, possible PCP, right, let me get this patient resuscitated and intubated…opening up her fluids while preoxygenating her.

Miraculously, the radiographers were in resus at the time and a CXR was done:

cxr

 

Quick glance at the XR – right, as I suspected – bad pneumonia, ARDS, but I was really just thinking of how I was going to safely intubate such a physiologically difficult patient. Once she was intubated and on the ventilator, I took a look at her heart. This ED only has an old ultrasound machine with an abdominal probe, but it was enough to deliver the diagnosis:

Parasternal Long Axis view: Doming of the AMVL can be seen with restricted opening of the mitral valve. The MV is thickened particularly at the leaflet tips. The LA is large.

 

Parasternal Short axis at the level of the MV: The valve is thickened with commissural fusion. This is severe Rheumatic mitral stenosis, confirmed later by a formal echo.

 

Lung ultrasound was done, showing B lines bilaterally, indicating pulmonary oedema. “By the way doctor, the urine pregnancy test is positive” Ultrasound of the abdomen was done next, showing a bulky uterus, no intra-uterine pregnancy noted and no pelvic free fluid.

Based on this basic echo, fluids were limited and the patient was diuresed. Cardiology was consulted, confirmed the diagnosis of MS. Balloon valvuloplasty was done and two days later she was extubated and was discharged home a while later. Her septic markers were negative. Later on it was discovered she had had a miscarriage a few days before presentation. The tachycardia induced by the haemorrhage had reduced ventricular filling, raised her left atrial pressures abruptly and pushed her into pulmonary oedema, unmasking her mitral stenosis.

Ultrasound can unmask a diagnosis not detected on physical exam. Mitral stenosis is a notoriously difficult murmur to detect. The doyen of Clinical medicine, Sir William Osler once said: Mitral stenosis may be concealed under a quarter of a dollar. It is the most difficult of heart diseases to diagnose.” This is Sir Osler, mind you. What hope is there for us with our pithy physical exam skills?

 

This is what this case taught me:

My initial diagnosis was wrong. The echo was basic; it did not yield great images but helped me reach the right diagnosis.

Bedside ultrasound can lead to more rapid diagnosis, and earlier appropriate management. The medical registrar who saw her didn’t believe she had MS, because he couldn’t hear it. Her diagnosis and management could have been delayed for days.

Patients can have more than one diagnosis or co-morbidity. The presence of HIV and heart disease, HIV and diabetes is common.

Elia et al published a case series in the American Journal of Emergency Medicine called “ultrasound to reduce cognitive errors in the ED” The link is here: Ultrasound to reduce cognitive errors in the ED

The paper describes cases where the use of point of care ultrasound altered the patient’s diagnosis and management. Each case demonstrated cognitive pitfalls and assumptions that the use of ultrasound helped to avoid. In the critically ill where decisions need to be made rapidly, ultrasound is an effective tool to check your reasoning and improve your management.

Be careful with interpreting poor quality images however; always get formal imaging, and ensure that you are properly qualified to interpret images before you incorporate them into your decision making on critically ill patients.

  • Kirsten Kingma

SMACC, the FOAMed Highlight of the Year

 3264 2448 Kirsten Kingma

 

It has been of interest to note that the vast majority of the traffic on #badEM has been via Facebook sharing rather than twitter. This may mean that many of you guys haven’t discovered the full potential of the FOAM (Free Open Access Medicine) community. The SMACC (Social Media And Critical Care) conference is in its third year now as was held in June in Chicago, USA. SMACC is one of the big highlights on most FOAMers calendar; it is essentially the heart and soul of FOAM. SMACC over the past 2 years has had such a big impact on my medical education and mind-set that I decided that I was going to attend this year even if it meant sleeping on the streets. The next few posts will summarise the key points that I took away from the conference. This post aims to give an overview of what it is all about and how medical education is in my mind, is evolving.

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In the simplest of terms, SMACC is a medical conference with an emphasis on critical care; the talks are all done in a Ted talk style. The audience is encouraged to participate in the talks through use of twitter; this is used as a platform to ask the speaker’s questions as well as share key points to others not present in the session. The speakers are chosen based on both their academic backgrounds as well as on their ability to present to an audience. The talks are informative but in a non traditional way; slides consists predominantly of pictures with minimal or no text, graphs and complicated slides are discouraged, speakers are talking on topics that they are passionate about and there are no intimidating suits and ties. It creates an environment where the audience can sit back, listen and engage with the topic at hand. Some of the talks I attended went to all new levels of extremes to engage with their audience; there was beer drinking during sessions, mechanical bulls, Milo given to the audience, passionate slips of profanity, and even some nudity. None of this distracts from the main topic at hand, it becomes clear that the speakers put months of thought and effort into how they can convey their message in the best possible way. The speakers are a heterogeneous mix of professions, cultures, genders and opinions. Debate and conflicting ideas is encouraged, often the talk carries on for many days through the Twitter platform. As a medical student, the best analogy would be to imagine one had been eating rice their entire life and now they had been exposed to the finest cuisine around, it becomes impossible to satisfy ones cravings and all you want to do is over indulge.

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In addition to the presentations there were multiple pre-conference workshops. This is where the magic happened. The workshops covered a variety of topics both clinical and non-clinical. The value in the workshops is that is creates an environment to interact with the varying experts on topics that interest you. The smaller groups allow for networking and socialising while simultaneously learning. I was involved with the emergency airway, emergency ultrasound and cadaver skills workshop. Pre-reading and video content were sent to attendees to encourage a flipped classroom scenario and post workshop surveys were sent out for future improvement. The stations were designed to give off core knowledge and skills in a practical hands-on manner with faculty members giving assistance and advice.

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The conference really distinguishes itself from any other through the emphasis on networking and socialising. Faculty, attendees, volunteers and students were all mingling constantly. Months before the conference #smaccRUN was created where everyone was welcomed to join in on a 5/10km run around Chicago. A constant buzz of open invitations to dinner circulated twitter daily. The gala dinner to which everyone attended was nothing short of a rocking music concert. A massive venue situated on Navy Pier housed many of the attendees till the early hours of the morning.

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While FOAM tends to create “super stars” of the industry, it was refreshing to see how approachable and “normal” everyone is. It is often frowned upon to socialise within the work environment, especially with ones mentors. I left Chicago with my mentors now as some of my close friends. The level of discussion and open communication drastically improves when people are able to connect with each other. The removal of hierarchy and constricting boundaries creates an interesting situation where the real things that we often hide from honestly discussing can be approached. While many may argue that it is essential to keep “professional boundaries” between mentors and mentees, I now tend to disagree. My opinion has changed more to the need for mutual respect for ones roles rather than restrictive boundaries.

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I would like to thank the organisers Roger Harris, Oliver Flower and Chris Nickson for giving me the opportunity to attend this one of a kind conference. If you haven’t seen any of the SMACC podcasts, check out:

Next year is #smaccDUB, I would highly recommend it to everyone! This has really been a paradigm shifting, mind-altering experience that I would recommend to every healthcare professional.

  • #smaccDUB: Dublin Convention Centre; 13 – 16 June 2016. Limited to 2000 attendees so if you’re keen be sure to register early (Registration should open around November but follow @smaccteam on Twitter to find out more)

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If you are not on Twitter: then I recommend you join today! A post will be out soon on “How to Get Your FOAM On” (and Twitter).

  • Kirsten Kingma

No electrodes, no problem

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The 2015 AfJEM Resource Innovation Competition

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

  1. You can only use materials that are locally available
  2. Your end-product should have comparable functionality to the product it aims to replace
  3. It should be simple to hack, concoct, devise or contrive
  4. It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

1st Place – Emmanuel Acheampong – ED Nurse – Ghana @achiegh

No electrodes, no problem

This is what Emmanuel had to say about his innovation: “There are times in the emergency department (ED) when there are no electrodes available to place patient on a monitor. In resource limited settings like Ghana, it is very expensive to replenish disposable electrodes and it is quite common to run out of electrodes in the ED. Improvisation in medicine has become a solution to daily problems encountered in resource limited settings. You can use cotton swab as a replacement for your electrodes.
1. Get three moderate sized cotton swabs and make it slightly moist.
2. Place the cotton swabs in position as you would electrodes for monitors.
3. Attach the probes of the monitor to the swabs and tape over the probe and swab as shown in pictures.
4. Turn on the monitor and inspect the ECG tracings”

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  • badEM
The 2015 AfJEM Resource Innovation Competition

A resourceful shoulder to lean on

 1100 612 Kat Evans

The 2015 AfJEM Resource Innovation Competition

In the preparation for the 19th World Congress on Disaster & Emergency Medicine held in Cape Town – AfJEM asked African Emergency Medicine lovers something interesting –

“Can you hack, concoct, devise or contrive a wanted resource using only locally available materials? You can..? Really..? Now you can show it off & win some amazing prizes”

The rules of engagement we were given were:

  1. You can only use materials that are locally available
  2. Your end-product should have comparable functionality to the product it aims to replace
  3. It should be simple to hack, concoct, devise or contrive
  4. It should be novel (not have been described before)

#badEM authors & friends quickly went hard at work to submit our “tricks of the trade” & were excited to hear about the entries at the conference. After numerous entries Dr Stevan Bruijns & the AfJEM team voted for a Top 5; described below.

2nd Place – Lauren Lai King

A resourceful shoulder to lean on…

Shoulder dislocations are a common acute orthopedic complaint presenting to emergency centres throughout South Africa. Post reduction immobilisation is essential in the recovery and rehabilitation period. This core management step is not always implemented as a result of resource limitations, most commonly the unavailability of shoulder braces.

I propose the innovation of makeshift shoulder braces utilising easily accessible resources.

1. Improvised “polysling with shoulder stabiliser” from collar and cuff – Foam bandage is folded around the neck from which the sling can be suspended. Cable ties are used to secure the foam bandage into a support sling for the arm. Free edges of the sling are tied around the trunk to provide stabilisation and ensures that the upper limb is securely adducted to the torso. The sling can be untied with the free, uninjured hand to release the injured limb as necessary. Assistance is required during the initial fitment process and during each application of the sling.

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2. Even more low resourced T-shirt shoulder stabiliser: In more resource limited settings, a shoulder sling can be created with the free edge of a t-shirt and 2 safety pins. The free edge of the t-shirt is folded up until the injured arm is supported in the shirt crease. The free edge is secured in place with a minimum of two safety pins. This creates an effective and user friendly solution. All aspects of the design can be completed by the injured individual with the uninjured hand.

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  • Kat Evans