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Emergency Care – See You In Court

150 150 Craig Wylie

#badEM19

In September 2019 we hosted #badEM19 an entirely free 1-day educational symposium. We would like to thank all our sponsors for making this possible. All the talks were filmed & edited by ER24 and will be released on the website. This event is run alternate years to our main conference.

Join us in watching Advocate Andrew Brown in discussing the current state of medical negligence litigation in South Africa.  Andrew is a practising advocate of the High Court and focuses on the defence of State and private hospitals, medical practitioners and paramedics in medical negligence litigation. He is also a Sergeant in the SAPS reserves and manages the child abuse team at Red Cross Childrens’ Hospital in this capacity.

Head Vs Heart: Opening the Box

925 520 Natalie May

Head Vs Heart: Opening the Box

This blog post has been co-released by StEmlyns and badEM

“Head Vs Heart: Opening the Box”  was intended to be presented by guest speaker and author, Natalie May at badEMfest20. Unfortunately, do to the current pandemic, badEMfest20 has had to be postponed and this talk would have had to wait until next year, however, Natalie wanted us to share the post. We feel that this topic is extremely relevant in the current climate that we as healthcare workers find ourselves in.

2019 was a bit of a mad year for me. I was appointed to a permanent post in Emergency Medicine in Sydney, I had a baby and I spent three weeks as a psychiatric inpatient in a mental hospital.

Wait. That’s not right

I was appointed to a permanent post in Emergency Medicine in Sydney, I had a baby and I was fortunate enough to spend three weeks as a psychiatric inpatient in a mental hospital.

That’s better.

I hope you’re not too shocked. I’ll admit, I was a bit surprised myself – the first 24h as an inpatient were totally surreal. But I’m not ashamed. I’m incredibly fortunate to have had excellent support from two awesome EM friends, to have access to NSW’s only mother and baby inpatient mental health unit and to have been admitted early, so much so that I was able to turn my surviving into thriving. I promise I’ll share more on my experiences of postnatal anxiety and depression (PNAD), the insights and tools I accessed through CBT and why Emergency Medicine is excellent preparation for parenthood (and why it’s not) in due course.

My family is doing well; I am weaning my antidepressant dose and back at work, and my son is a happy healthy 9 month old.

For now, though, there’s something I learned in the unit that I really think you need to hear. In fact, it absolutely blew my mind to attend this session and I still can’t believe that this isn’t something we are taught in healthcare.

I want to talk about EMOTIONS.

I bet you thought this was going to be a talk about thoracotomy and trepanation, right? Well, don’t go anywhere just yet. I think this is going to be more useful to you on a daily basis and relevant to all of you. That’s right – everybody.

The following is based on a session delivered by an amazing psychologist during my inpatient stay (thank you Sarah!).

Emotions

Growing up, we hear lots of messages about our emotions. Maybe you were told that “boys don’t cry”. Perhaps you’ve been accused of “moping around” or told that you have “an anger problem”. Maybe you struggle with “Catholic guilt”. Whatever your experience, I think most of us can relate to the idea that society would have us believe that some emotions are good and some emotions are bad.

But consider this: what would the world look like if there was no anger? Too much anger would be chaos and violence, but if there was none there would be no boundaries; anything could be done by anyone to anyone – and that’s chaos too.

What about sadness? If there was no sadness, life would be frivolous. And without guilt, we wouldn’t be motivated to do anything differently.

Psychologists tell us that there are six main emotions – this idea comes from the work of Paul Eckman in the 1970s although much of his work was around decoding facial expressions. Since then, work around understanding emotions has built on the idea of core emotions and there are several versions of this (Robert Plutchik described eight in pairs, and displayed them in a colour wheel) but the underlying principles are the same. Other words we use to describe how we feel can be sorted into one of these six categories, and each of the six main emotions serves a specific purpose.

Fear

The purpose of fear is to protect us from danger and ensure our survival.

If there was no fear, we would put ourselves into dangerous situations. Too much fear is debilitating; it prevents us from doing the things we want to do.

Anger

Anger exists to tell us that a boundary has been violated.

Without anger, we would not be able to protect ourselves and our interests. We would find others taking advantage of us. Too much anger can hurt those around us, destroying our relationships.

Shame

(Eckman called this DISGUST, but I think shame is easier to understand)

We feel shame in order to motivate ourselves to develop or improve certain parts of ourselves.

If we didn’t feel shame, we would continue to do things that harm ourselves and others. Too much shame is also paralysing; it would cause us to withdraw from society, to experience low self-esteem and to isolate ourselves from others.

Sadness

The purpose of sadness is to show us what matters to us.

Without sadness, life would be superficial. We wouldn’t form meaningful relationships or realise the value of other people and things in our lives. Too much sadness prevents us from functioning, as those with depressive illnesses know.

Love

Love helps us to form attachments and connections.

If we didn’t feel love, we wouldn’t meet our need for community and connection. Too much love can impair our logical thinking, particularly if we become infatuated.

Happiness

We experience happiness to reward behaviour that benefits us.

Without happiness, we would lack enjoyment in life and particularly in social connections (think about the times you are most happy; they usually involve a moment of taking stock and often involve other people). Too much happiness means we wouldn’t understand our limits and we might prevent other people from being able to live their lives.

Why this – and why now?

We are living and working in unprecedented times.

As an Emergency Physician I have often thought that my emotions get in the way of my ability to do my job. I might even have described myself as “dead inside”, used so-called “black humour” in stressful situations or even walked from breaking bad news straight into a consultation where I play with a toddler. I’ve thought of myself as a “head” person far more than a “heart” person and I wonder how many of you can relate to this.

While the idea of emotions being a nuisance at work might be true in some ways, my approach of just pretending to myself I didn’t feel anything was not the most functional. It’s also an unfair way to treat myself, because I’m not a robot and I do feel things. There are tough resuscitations, failed resuscitations, horrible deaths and little moments of collateral beauty that stay with me. In truth, I have been afraid to open the box I’ve kept my emotions in because I was scared that they would never stop pouring out. I am fallible, imperfect and human, and so are you.

Logically, emotions do make sense; they are crucial to our survival as they drive us towards togetherness, towards a functioning social group – and that, I think we are about to find out – is the essence of our humanity. I’m bringing this concept to you now because I think we are going to find our emotional responses unavoidable in the coming days, weeks, months and years as we work and live through this crisis.

We often judge ourselves for “feeling”, especially when we have listened to society and attributed “good” or “bad” tags to particular emotions. As a psychiatric inpatient I learned about the concept of self-validating my emotions. Validation means not judging myself and not judging the emotion, simply accepting that I feel what I feel in a particular situation. Adding judgement often fuels further unhappiness. In this case, we might feel anger or fear as a secondary emotion in response to our primary emotion (for example, sadness).

Self Validation

The key is acceptance; this can prevent us from falling into the trap of allowing secondary emotional responses. Freeing up our emotional and cognitive processing power by accepting what we feel allows us to do more to change our situation (if we need to).

Self-validation has three stages. If this is totally new to you, you might not be immediately able to proceed to the third stage – and that is completely fine. I would, however, advise you to practice now. Self-validation is a skill, and like all skills the more you practice, the smoother and more natural it will become. That may be valuable in the ensuing weeks.

Step 1: acknowledge

This is perhaps the hardest and most important step; name the emotion that you feel and let go of any associations with feeling it.

I have talked a few people through this process in recent weeks and often when you ask someone “how do you feel?” they immediately begin talking about their judgement of the situation, eg “I can’t believe that he was so rude to me!” or “It’s so irritating that they did that!”

Try to let go of the judgement and discern how you feel. Put a name to that feeling and say it out loud.

I feel angry.

I feel sad.

If you are able to align your emotional state with one of the six main emotions, that’s great – if not, try to work out which main emotion the word you are using to describe the way you feel falls into.

Step 2: allow

Allow yourself to feel that emotion. It is the way you feel – and that is ok. Tell yourself that. Give yourself permission to feel what you feel; as we have already discussed, there are no “good” or “bad” emotions.

I feel sad. It is ok that I feel sad.

I feel angry. It is ok that I feel angry.

This might be as far as you can go initially. That is totally fine.

When you are comfortable naming and allowing your emotions, try to move to step 3.

Step 3: understand

Once you can identify which of the six main emotions you are feeling, you can refer back to the purpose of that emotion to try to understand where it comes from. Sometimes we do feel a mixture of things at once, so try to take them on one at a time.

I feel sad. It is ok that I feel sad. It is understandable that I feel sad; sadness exists to show me what matters to me. It matters to me that I am good at my job and things here didn’t go the way I wanted them to. My family matters to me and I saw the pain of losing them reflected in the pain of my patient’s family.

I feel angry. It is ok that I feel angry. It is understandable that I feel angry; anger exists to tell me that a boundary has been violated. In this situation, that boundary is the respect I expect to be shown in my workplace by my colleagues.

Understanding your emotional response goes beyond judgement and attempts to make sense of the way that we feel. This is difficult, but gets easier with practice. I would suggest taking a moment to self-validate your emotions at minimum once a day; as you are leaving work would seem to be a good time to check in with yourself, but as things get harder you might want or need to do this several times a day.

And that’s it. Acknowledge, allow, understand  – three steps to help you to take care of yourself; to prevent things being bottled up inside and to check in with your emotional state in a non-judgemental way.

I hope this helps you to stay well. I suspect that you, like me, will be more whole, more productive, and more peaceful if you accept both head and heart – and trust yourself to open that box.

Low-Cost Surface Disinfectant

757 1004 Kat Evans

Low-Cost Surface Disinfectant

Traditionally in our departments, we have used alcohol-based sanitizers to wipe down surfaces and objects. With massive shortages of consumables and supplies during the COVD-19 outbreak, we have to look at cheaper alternatives that are readily available and are as effective. Household bleach, diluted to an appropriate concentration is recommended by the WHO for surface disinfectant. Due to its low cost, this is an ideal option for LMICs, both at healthcare facilities as well as staff members’ homes.

How to make the correct mix of bleach for wiping surfaces, keys, phones (careful), door handles and cards for COVID-19

What you need

Any bleach is fine, as long as it’s between 3.0% – 3.5% sodium hypochlorite (written on the bottle)

Add 25ml of bleach to an empty 750mls bottle to make a 0.1% solution
Add 93ml of bleach to an empty 750mls bottle to make a 0.5% solution
[Guidelines vary, with European/Australian listing 0.1% but WHO/CDC recommending 0.5% for a surface cleaner – Thank you to Dr Sarah Ashley for contributing!]

Top up to 750ml.

If you are using different size bottles, the ratio is 1:29 for 0.1% or 1:7 for 0.5%

Label the bottle for safety

Perfect Mix in Retrieval

150 150 Eric de Korte

#badEM19 – 1 DAY Free Symposium

In September 2019 we hosted #badEM19 an entirely free 1-day educational symposium. We would like to thank all our sponsors for making this possible. All the talks were filmed & edited by ER24 and will be released on the website. This event is run alternate years to our main conference.

Join us in watching Dr Nevil Vlok in the final installment of a four-part series outlining the Emergency Care Framework. He outlines the retrieval of a trauma patient from a South African District hospital to a tertiary hospital.

For more discussion in Emergency Medicine and what we can learn from each other, come join us in March 2020 at #badEMfest20

Get your tickets NOW for this unique 4-day all inclusive conference

Trauma Care in the District EC

1600 1200 Eric de Korte

#badEM19

In September 2019 we hosted #badEM19 an entirely free 1-day educational symposium. We would like to thank all our sponsors for making this possible. All the talks were filmed & edited by ER24 and will be released on the website.

Join us in watching Dr Nuraan Lotter in the third installment of a four-part series outlining the Emergency Care Framework. She outlines the treatment of a trauma patient in a South African District hospital.

For more discussion in Emergency Medicine and what we can learn from each other, come join us in March 2020 at #badEMfest20

Get your tickets NOW!!

Prehospital Haemostatic Resuscitation

639 639 Eric de Korte

#badEM19

In September 2019 we hosted #badEM19 an entirely free 1 day educational symposium.

The second instalment of a four part series of talks outlining the Emergency Care Framework. Below watch the presentation by Dr Matt Gunning on Haemostatic Resuscitation in the prehospital setting.

Community First – Kevin Jones

1080 1080 Eric de Korte

#badEM19

In September 2019 we hosted #badEM19 an entirely free 1 day educational symposium. We would like to thank all our sponsors for making this possible. All the talks were filmed & edited by ER24 and will be released on the website.

We start off with the first of a four part series of talks outlining the Emergency Care Framework. Below watch the presentation by Kevin Jones on the role of Community Responders.

Come join us in March 2020 at #badEMfest20 to have more interactive discussions.

Crash 3

448 232 Willem Stassen

The iPhone 11 of the emergency medicine world has just been released and you should be queueing for the results.

The badEM crew and some guests sat down to understand what this landmark trial means for us in Africa. After reading the appraisal listen to our podcast and to our opinion on what these results mean in our settings.

Appraisal : Willem Stassen and Michael McCaul

Podcast:

The why and what?

Trauma accounts for approximately five million deaths annually, (1) an estimated 90% of these occur in low- to middle-income (LMIC) countries. (2) Traumatic brain injury (TBI) has been described as the most important single injury contributing to morbidity and mortality following trauma. (2) In LMICs, the probability of death from TBI is double than in higher-income countries (HICs). (3) Expected to become one of the leading causes of death; TBI occurs predominantly in younger, economically active populations and may thus have far-reaching social effects.

TBI is often complicated by intracranial haemorrhage which may contribute to mortality by increasing intracranial pressure and culminating in cerebral herniation. It has been postulated that reducing intracranial haemorrhage by minimizing blood clot breakdown (fibrinolysis) may limit the size of intracranial haematomas and its subsequent deleterious effects. Tranexamic acid (TXA) has been shown to prevent fibrinolysis in extra-cranial traumatic haemorrhage, having a positive impact on mortality. (4)

According to a meta-analysis of two trials, (5,6) TXA may reduce mortality rates in patients with TBI. However, these studies are limited by small sample sizes and do not provide conclusive evidence around the safety and efficacy of TXA in TBI. The CRASH-3 trial aimed to determine the effect of TXA on morbidity, mortality and the incidence of adverse events in patients with TBI.

How was it done?

The CRASH-3 trial is an international, multi-centre, parallel-arm randomised controlled trial across 29 countries from 175 hospitals from July 2012 to January 2019 of adult patients with TBI.

  • Population: Adult patients with TBI within 3 hours of injury, GCS ≤12 or any intracranial haemorrhage (ICH) on CT, with no significant extracranial bleed. Changed from within 8 hours to 3 hours following new evidence during trial conduct.
  • Intervention: TXA 1g infused IV over 10 minutes (loading dose), followed by 1g IV over 8 hours.
  • Comparison: Matched placebo (0.9% Sodium Chloride).
  • Outcomes, Primary: 28-day TBI death.
    • Secondary: Early TBI death (within 24 and 48 hours after injury), all-cause and cause specific mortality, disability, vascular occlusive events (MI, stroke, DVT, PE), seizures, complications, neurosurgery, ICU LoS, adverse events within 28 days.

Importantly, patients were randomised only if the treating clinician had doubt as to whether TXA was indicated in the patient or not. This is an important ethical consideration when specific treatment has proven benefit in a subgroup that may potentially be sampled as part of a trial – an effective treatment is therefore not withheld from a patient that may benefit from it.

Patients were randomised centrally by an independent service, allocation was concealed and blinding of clinicians and the analysis team was maintained.

Delayed consent was sought from participants with proxy consent serving as initial inclusion. If a proxy was not available, a participant was enrolled if two clinicians agreed. It is unclear whether these clinicians were investigators in the trial. What is also unclear is whether the community was engaged prior to the start of the trial – this is normally a proviso for delayed consent trials. It is likely that this was done, but not discussed in the main paper.

What did the study find?

When excluding patients with severe TBI and those with unreactive pupils (severe TBI with poor prognosis at the outset), there was no difference in head injury death between TXA and placebo (RR=0.89, 95%CI 0.80-1.00). However, when considering the totality of available evidence in trials of patients with severe TBI, a meta-analysis of the two trials (including CRASH-3) shows TXA reduces death when compared to placebo (RR 0·89, 95% CI 0.80-0·99), with no evidence of increased adverse events.

Additionally, TXA, is effective in patient with mild to moderate TBI compared to patients with severe TBI (RR 0.78, 95%CI 0.64-95). Overarching, TXA is more effective the earlier the drug is administered, especially in mild to moderate TBI patients, whereas in severe TBI patients there is no effect by time to treatment. When considering the meta-analysis effects, one would need to treat 50 patients in

Although not statistically significant (One cannot help but wonder whether this is related to the specific challenges of  access to emergency and neuro-intensive care in LMIC settings. We discuss some of these contextual findings in the podcast.

So What?

In CRASH-3 randomisation was done appropriately and allocation of the next assignment concealed from study participants and staff. Importantly, randomisation was successful as there was no major evidence of baseline clinical imbalances between groups. Investigators were blinded to which intervention was being received, and this is well described. Especially for patients, blinding is less critical as objective outcomes were being measured. Considering the large sample size of the trial there was minimal and non-differential loss to follow up of patients across the two trial arms. Furthermore, authors reported as per their published protocol in 2012, indicating appropriate outcome reporting. Overall, there seems to be minimal red flags indicating any major risk of bias that would cast doubt on the validity of the trial findings.

Traumatic brain injury is quite sensitive to early insults of hypotension, deranged carbon dioxide levels and hypoxia. It is unclear whether the patients included in the CRASH-3 trial suffered any of these insults earlier. When we consider that out-of-hospital (and/or early care) is often lacking in LMICs it is not surprising that TXA had a smaller effect in these settings. It would therefore be forgiven if TBI management in these settings was focused on preventing these secondary insults instead.

A secondary outcome of the study was the requirement for neurosurgery.  This was not reported in the analyses. Were more patients in the TXA group afforded neurosurgery, and this might be the reason for the treatment effect? It is further important to consider that TBI management is multidisciplinary – do you have immediate access to neurosurgery? More importantly for LMICs, can TXA prevent the need for neurosurgery by limiting the size of the ICH? More on this in the podcast.

Considering the massive socio-economic impact that TBI-associated morbidity has on families and healthcare systems, it would have been nice to see an appreciable change in these with the use of TXA. Unfortunately, for all morbidity measures this does not seem to be the case (95% confidence intervals cross the line of no effect). In some instances, the mean RR favours placebo (i.e. patients seem worse off with TXA). We explain this with “survival bias” – patients who would have died from their injury now lives with a disability instead.

Although, we could go on forever about this well-executed trial, one other aspect related to LMICs in particular is the inclusion criteria – GCS ≤12 or any ICH CT. It is unclear how many patients were enrolled using the GCS criteria and how many were enrolled following imaging. More importantly, it is unclear how many patients were enrolled on GCS and later found to have no radiological evidence of ICH (could this have diluted the treatment effect?). In any event, considering that TXA is most likely to benefit patients with mild-to-moderate TBI with ICH and has a time-to-treatment effect that diminishes, the real question is whether this population will receive timely CT scans in the settings that we work within. At the very least, we know that giving TXA to a trauma patient with a concomitant TBI does not appear to cause harm.

Some of our friends have also reviewed the study. Please do read/listen to these as each person looked at the study from a difference lens. Great work friends.

St Emlyn’s have also given their perspective on the CRASH3 Trial: Click here 

Josh Farkes from PulmCrit give his perspective on CRASH3

The Skeptics’ Guide to EM has Salim Resaie as a guest author also reviewing the trial.

Simon Rob and James from The Resus Room: Click Here

From REBELEM, CRASH-3: TXA for ICH?

From EMLitofnote Ryan Radecki: Click Here

REFERENCES

  1. Murray CJL, Barber RM, Foreman KJ, Ozgoren AA, Abd-Allah F, Abera SF, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet. 2015 Nov 28;386(10009):2145–91.
  2. Eaton J, Hanif AB, Grudziak J, Charles A. Epidemiology, Management, and Functional Outcomes of Traumatic Brain Injury in Sub-Saharan Africa. World Neurosurg. 2017 Dec;108:650–5.
  3. De Silva MJ, Roberts I, Perel P, Edwards P, Kenward MG, Fernandes J, et al. Patient outcome after traumatic brain injury in high-, middle- and low-income countries: analysis of data on 8927 patients in 46 countries. Int J Epidemiol. 2009 Apr 1;38(2):452–8.
  4. CRASH-2 trial collaborators, Shakur H, Roberts I, Bautista R, Caballero J, Coats T, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23–32.
  5. Perel P, Al-Shahi Salman R, Kawahara T, Morris Z, Prieto-Merino D, Roberts I, et al. CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage) intracranial bleeding study: the effect of tranexamic acid in traumatic brain injury, a nested randomised, placebo-controlled trial. Health Technol Assess (Rockv). 2012 Mar;16(13):iii–xii, 1–54.
  6. Yutthakasemsunt S, Kittiwatanagul W, Piyavechvirat P, Thinkamrop B, Phuenpathom N, Lumbiganon P. Tranexamic acid for patients with traumatic brain injury: a randomized, double-blinded, placebo-controlled trial. BMC Emerg Med. 2013 Nov 22;13:20.

Interview with the Author: Michael McCaul on South African prehospital guidelines

150 150 Craig Wylie

Series: “Interview with the Author…”

Link to open access article: Click here

Corresponding author email: mmccaul@sun.ac.za

Previous linked author interview: https://badem.co.za/afjem-mccaul/

Author’s twitter handle: @MikeMcCaul3

Co-authors: @Research_ambit and @CEBHC

Youtube: Strengthening South African prehospital guideline uptake

Published in: @Plos Volume 14 Issue 14

The badEM crew interviewed Michael McCaul regarding his newly released article in PLoS ONE Volume 14 Issue 7 entitled: “Prehospital providers’ perspectives for clinical practice guideline implementation and dissemination: Strengthening guideline uptake in South Africa.” by Michael McCaul, Lynn Hendricks, Raveen Naidoo. 

 

1. Tell us about yourself and how you got involved in this research?

In 2016, I was involved as a methodologist in the development of the South African AFEM Clinical Practice Guideline (CPG) for the Health Professions Council of South Africa. Following that project, we knew that getting the guideline into practice would be a challenge and we as a profession need to acknowledge and address some challenges if these guidelines are to work in practice. Finding solutions to the challenges needed to start with a solid understanding of what the problem is and so we did some research across South Africa to find out. We asked paramedics what they expected to see from the guidelines, to let us know what they expected to be particularly challenging in using them and, importantly, to give us their ideas on how best to implement them.

2. What were the findings?

We received valuable input that will help decision makers disseminate and implement these new emergency care guidelines. Key solutions focused around communication, technology, autonomy and education; highlighting the need for clear and consistent communication from stakeholders, the creation of inclusive career pathways and an end-user document that helps the transition process.

We will act on these findings and our main message to you is that this guideline, based on the best available evidence, is now available for South Africa. Successful uptake will require an understanding of the contextual issues and solutions of the end-users of the guideline. The need for clear communication between stakeholders and a clear implementation plan that is contextually appropriate is recognised and will be developed in order to strengthen guideline uptake.

In order to make sure that our findings are used by the right people, we involved decision makers at the start and throughout the project. These included people from the national department of health and support from the professional board of emergency care. We shared our findings with them, and are now working together to inform conversations among decision makers around getting the evidence into policy and practice, to achieve our ultimate goal of benefit for our patients.

If you want more detail on what we did, then read our open access publication in AFJEM, follow us on Twitter, or check out this useful research summary and infogram.

Check out the full-text open access article:  Click here

Voices from Africa at SMACC

150 150 Craig Wylie

African Voices at SMACC

During SMACC in Sydney, Doug Lynch, @thetopend, interviewed several African delegates.

We would like to take this opportunity to acknowledge the conference organisers with the smaccREACH program.

We are super excited for the future of SMACC under their new banner CODA.

Pendo George, from Tanzania, was the first to be interviewed by Doug for the Jellybean Podcast.

For more information go to Emergency Medicine in Tanzania.