Podcast

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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.

#badEMfest18: The Chronic Pain Toolkit – Rowan Duys

150 150 Craig Wylie

The Chronic Pain Toolkit 

Dr Rowan Duys 

Rowan, @healthink, is an Anaesthetist practicing at Groote Schuur Hospital in Cape Town, South Africa. He has a key interest in pain management & simulation teaching.

 

Rowan has been a great friend of the badEM crew and joined us at #badEMfest18 to share some great pearls of wisdom on chronic pain.

For some extra resources please visit:

https://www.tamethebeast.org/

https://www.retrainpain.org/

Watch out for #badEMfest20 coming soon.

Thoughts from the Intro to Pain Control in Palliative Medicine Diploma

150 150 Kat Evans

Day 3 Pain Management Introduction was taught/facilitated by Dr Rene Kraus.   I will in the future post my version of the “Pain Masterclass” when we do an entire section of the Diploma on pain management.. 

  • When thinking about how we can stop pain in its tracks: we have to think in terms of ascending & descending pathways..
  • Different drugs work on different parts of the pathways, BUT pain is experienced by people & families not nerve pathways!
  • Pain is experienced TOTALLY, and we need to modulate it TOTALLY.
  • NB: The amount of pathology does not equal to the amount of pain. 
  • Pearl of wisdom from Rene: some patients with chronic pain/illness claim to be coping well independently.. have a look at their toenails.. can often give clues on how well the pain is ACTUALLY affecting their functioning!

I would highly recommend my classmates & people interested in dealing with chronic pain in the Emergency Centre / Primary Healthcare / Palliative Medicine watching the below 2 talks by badEM’s friends Iain Beardsell & Rowan Duys

Here are some fantastic resources from Rowan:

https://www.tamethebeast.org/ Great analogy & videos useful for both clinicians/patients/community.

https://www.retrainpain.org/ Fantastic resource for patients, also translated into Afrikaans! Any volunteers in South Africa able to assist translating into more South African languages?

Back to School: Day1 of Palliative Medicine PGDiploma

150 150 Kat Evans

I have made the decision to put my student hat back on and start a 1 year Postgraduate Diploma in Palliative Medicine through UCT this year. Day 1 discussions were facilitated by Dr Rene Kraus. Our class are a fascinating group of largely very senior/experienced palliative medicine doctors/nursing staff/allied health colleagues. I am excited to collaborate and learn from the group

History of Palliative Care & Hospice

Hospice traced back to medieval times:
“The first hospice or monastery was built in the 9th century at Bourg-Saint-Pierre, which was mentioned for the first time around 812-820. This was destroyed by Saracen incursions in the mid-10th century, probably in 940, the date at which they also occupied Saint-Maurice. Around 1050, Saint Bernard of Menthon, archdeacon of Aosta, regularly saw travellers arriving terrorised and distressed, so he decided to put an end to mountain brigandage in the area. With this in mind, he founded the hospice at the pass which later bore his name. The church’s first textual mention is in a document of 1125. The hospice was placed under the jurisdiction of the bishop of Sion, prefect and count of Valais, thus explaining why the whole pass is now in Swiss territory.” – Wikipedia

The Modern Hospice Movement

Dame Cicely Saunders introduced modern hospice movement (click here to read more about her, she was a phenomenal lady who was a nurse, social worker and a medical doctor). She started St Christophers Hospice and the Cicely Saunders Institute 

Where did the concept of ‘Palliative Care’ come from? Dr Balfour Mount from Canada proposed the word palliate, which comes from latin word Pallium which means cloak, because symptoms are “cloaked” or “disguised” with treatments whose primary aim is to provide comfort even if cure is not possible.

Palliative Care Principles – WHO Definition:

Palliative Care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual…. [click here for further part of WHO definition] 

Dr Kraus unpacked the above definition for us into its components:
  • What is QOL? Depends on individual values, presence and absence of certain symptoms. QOL is fundamentally unique to each individual! Don’t apply your version of what good quality of life is to your patients.
  • What is a family? Legal family vs the people the patient perceives to be family.
  • What is a life-threatening illness? Difficult to define and very important to base on your context. Interesting in the international oncology discussion on this topic they spoke about ‘progressive metastatic cancer’, an African oncologist asked that instead we change this to ‘metastatic cancer’ due to different management strategies/interventions available. The SPICT Tool is useful in this regards BUT remember doesn’t mention TB/HIV which is key in our setting.
  • What is suffering? Suffering (patient, family & community) is multi-factorial. Important that suffering & discomfort are not the same thing. Discomfort may be normal or actually necessary.
  • What is spirituality? We will discuss this at a later stage.. as we are doing an entire week theme on it.. Important to understand that Spirituality does not equal Religion. 

Some thoughts/discussion points brought up regarding the definition: Important that not only TREAT suffering, but PREVENT suffering in the first place. Dr Kraus alluded to when her interest in PC began, which was working in rural SA in the height of the AIDS pandemic when ARVs were not yet available. At that stage there was no treatment option available. Something that is discussed a lot in EM circles.. regarding dying as a normal process. Using the “natural death” terminology. We discussed that dying and death is a process/journey not an event. 


Will try and post regular “African” context Palliative Care pearls as the Diploma proceeds