#FOAMed of the Week: The Semantics of End of Life Discussions via EMcrit.org

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Great Post and Podcast from Scott Weingart featuring Ashley Shreves on the practical steps to introduce these discussions in an ED setting. 

“End of Life Conversations are Hard

We stumble, we stutter, we say things that derail the discussion when we have a patient at the end of life. But how do we learn to do better? We model good behavior. But in order to do that we need to hear good discussions. I listened to Ashley Shreve’s amazing SMACC Chicago talk: What is a Good Death?

After listening, I wanted to bring Ashley back on to really get into the nitty-gritty of the semantics of End of Life discussions. Ashley has been on the EMCrit podcast before discussing Critical Care Palliation. Now lets hear from here again…

Tidbits I pulled out of the Podcast

The three patients that will spur Ashley to try to have these discussions:

1. Advanced Cancer or Terminal Disease with Instability

2. Advanced Frailty/Dementia with Instability

3. Advanced Physiological Age (>85 y/o) with Instability

Start with, “I’m so worried about your family member,” and see the response

Then, “Tell me how things have been going with your family member”

Technique: Ask, Tell, Ask, Tell

Know the trajectories of care for the diseases we deal with

Does that mean you will do nothing? No, we actually want to intensify the treatment, with a focus on peace and dignity

We don’t want to artificially prolong the dying process

Vitalists comprise 5-10% of the population, you are unlikely to convince these folks in the ED

What if things don’t get better?”

— http://emcrit.org/podcasts/semantics-end-of-life-discussions/

#FOAMed of the Week New Years Resolution: Papers of January via @HEFTEMCAST. Keep your EM current in 2016!

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“This year I solemnly swear to keep up to date with the latest in EM literature......”

— Me, every year......

Thankfully this year the wonderful team from @HEFTEMCAST are here to make that promise a little easier to keep. A new feature gives us a monthly summary of the most recent EM relevant journal articles with a little bit of critical appraisal along the way. 

You can listen to the podcast below, but far better is to subscribe to the podcast (itunes/pocketcasts  etc) and check out the website for a written summary.

Finally theres LOADS more out there in the #FOAMed world to make keeping up to date a breeze. Blogs and podcasts, get 'em on your feed reader or follow on twitter to get the latest EM research brought to your phone or tablet. Easy. 

Here's a recommended list: Life in the fast lane Research & Reviews, EM Literature of Note, Annals of EM Audio Summary, St Emlyn's Journal Club, The Bottom Line, the Skeptics Guide to EM, and EM Nerd.......actually theres loads more but I have to stop somewhere!

Happy 2016!!

#FOAMed of the Week: Dizziness Made Easy via @PeterJohns84 and @RCEMFOAMed

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OK.......actually this is more than one FOAMed article.......but its going to get your understanding of vertiginous dizziness off to the right start. From here you can start to think about the HINTS exam with more confidence, helping us differentiate central from peripheral causes of vertigo. 

First up watch these 2 excellent videos from Peter Johns, an Emergency Physician in Ottowa. Differentiating between Acute Vestibular Syndrome and BPPV is the biggest contribution we can make to the patient's care. This can be done just on the history.

Then a brilliant video from Michael Kim a UK EM trainee showing a Neuro SpR performing a Hallpike, Epley and your new best friend: THE SEMONT MANOEUVRE. The video won't embed here so go to RCEMFOAMed.co.uk to see it and the explanatory notes.

#FOAMed of the week: Acute Traumatic Coagulopathy by Karim Brohi via SMACC14

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With pre-hospital blood coming to South East Scotland its past time to find out why we're making such a fuss about it..... PLUS see below to get the low down on ROTEM!

“Karim Brohi highlights the pitfalls of fluid resuscutation and the deadly spiral of coagulopathy in severe trauma.”

— http://www.smacc.net.au/2014/08/acute-coagulopathy-of-trauma-by-brohi/

See Practical-Haemostasis.com's guide to TEG and ROTEM, plus watch the video below (technically its about TEG but similar principles). Boths links from the ever amazing: Life in the fast lane.

#FOAMed of the Week: Pseudoaxioms and Dogmalysis, from SMACC15, Via ICN

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Another talk from SMACC Chicago, this time from David Newman covering some favourite subjects.  Reminding us why we should know the evidence behind medical lore (and remain sceptical of wannabe new medical lore). Make sure you listen 'til the end, to include how medical students and junior doctors should handle #FOAMed Dogmalysis........

He and his wife, Ashley Shreaves, produced a number of brilliant podcasts on critical appraisal and EBM on SMART-EM which played a huge part in my passing my FRCEM.  

He also started the EBM website theNNT which produces EBM summaries on a variety of topics and is well worth checking out once you've got your basic stats in your head. 

Finally please listen to the monthly podcast Drs Newman and Shreaves produce for the Annals of Emergency Medicine Audio Summary. It's easy (and entertaining) listening and helps keep you up to date with latest publications. 

The Podcast:

#FOAMed of the Week: Sepsis SMACCdown via EMcrit

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SMACC Chicago, brought to your armchair in dark n stormy Edinburgh. Viva la #FOAMed

“An all-star panel discuss the burning issues in sepsis right now. Hosted by Chris Nickson and I, the conversation on the controversial aspects of sepsis was lubricated with on-stage alcohol (my idea!)

Mervyn Singer (research guru, sepsis expert and self-proclaimed Sex-God) and Paul Marik (iconoclast and dogma-basher) reveal just how hard it is to describe what sepsis is. Flavia Machado (intensivist and researcher) brings common sense and the perspective from South America, representing middle-income countries. Kath Maitland (author of FEAST, African-based paediatrician and clinical trialist) talks about sepsis management issues in Africa, where sepsis strikes its biggest global impact. Heavyweight researcher and clinician John Myburgh, argues that the word “sepsis” should be removed from our language and turns the paradigm on its head, arguing for a more pragmatic approach to sepsis management. Simon Finfer (crit care clinician, clinical trialist, voice of reason) describes the history, the good, the bad and the ugly about the Surviving Sepsis Guidelines, and some of the controversy surrounding them.

There’s a fascinating, very high level discussion on antibiotics which is not as clear cut as you might imagine. You couldn’t discuss fluids without talking about fluids and this panel features several world experts on this topic. Kath Maitland’s insights from FEAST, combined with the opinions of the rest of the panel will hopefully leave you an informed agnostic.”

— http://emcrit.org/podcasts/sepsis-smaccdown/

#FOAMed of the Week: Acute Heart Failure via heftEMcast.co.uk

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An excellent EBM based summary of the management of Acute Heart Failure for UK based EM trainees. Podcast below, but go to the website and subscribe to the podcast to get the full warm glowing feeling of knowing your up to date in an EM staple. 

heftEMcast is produced by the Heart of England NHS Trust Emergency Department. They aim to help keep our practice up to date with the latest EBM. 

#FOAMed of the week: ACID-BASE EMCrit Style - All time classic!

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This we're going back to some pretty old posts from EMCrit - but an all time classic!!

Acid Base is a traditional brain melter for me and these podcasts have been amazing in helping get to grips with it from the ground up. Its in...... (gulp) 5 parts....BUT there was a recent related post from EM Nerd (Rory Spiegel) on EM Crit talking through the equally confusing anion and osmolar gap. 

Click the links below to go straight to the relevant EMCrit page with all the associated show notes, or to get started watch the videos below. 

One things for sure......we'll all gonna be a lot....SMARTER! 

ACID BASE Part I:

ACID BASE Part II:

ACID BASE Part III:

ACID BASE Part IV: (Fluids)

ACID BASE Part V: (bicarb)

#FOAMed of the Week: #weneedtotalkaboutLACTATE via stemlyns

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Another publication from the illustrious EMERGE landed on my doormat on Friday, this time exploring the utility of lactate in the Emergency Department. Yet my understanding of lactate was turned on its head at SMACC Chicago, and it's head has never been the same since.....

Lactate NOT an acid?  Lactate NOT just caused by tissue hypoxia?

There's no doubt lactate is invaluable in assessing critically ill patients, but if we are to use it more, shouldn't we understand it better?

Another chance for #FOAMed to shine, as St Emlyns step up (again) in the hour of need. Richard Carden (EM Trainee) writes an excellent blog covering dead parrots, whoop whoops, AND some physiology my brain can actually digest. 

Check out the blog here: Lactate = LactHATE

Don't forget to look at the links at the bottom of the article and also look out for the SMACC Chicago talks on the same in the future. 

Viva la #FOAMed

#FOAMed of the Week: Induction podcasts via St Emlyns and HEFTEMCAST

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The Edinburgh Festival Fringe is the largest arts festival in the world. The thousands of visitors and performers arriving in the city make for a great atmosphere, but also mean we can rely on August being a busy month for our new doctors in the ED. 

Hopefully you are all finding their feet now and are ready for some new induction podcasts from the great folks at St Emlyn's and HEFT EMCast. Check out their websites for the accompanying blogs and notes. 

St Emlyns bring you:

Back to Basics: Back Pain

HEFT EMCAST bring you up to date with a classic ED diagnosis:

AF in the Emergency Department

Finally please check out the new #FOAMed Induction Course recently released at St Emlyn's website. 

#FOAMed of the week: Surgical Cricothyroidotomy via Emcrit/Levitan

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We had our first Edinburgh EM BossSIM this week, which amongst other nightmares included an unexpected 'Can't intubate, Can't ventilate' Scenario.  There was some great chat in debrief about the procedure and the different techniques taught and used. 

So this inspired a review of some vodcasts on a #FOAMed favourite - the surgical airway. 

This is a rare, critical and therefore stressful procedure.  Thinking it through well before you find yourself doing it is essential preparation.  #FOAMed is here to help!

EMcrit.org features some great info on how to avoid the stress of the context from bringing you off track, making  this procedure as simple as it should be. 

Below is a talk from Richard Levitan at the Emcrit conference in 2014. Critical points include the ergonomics of your approach, making the landmarks simple to find under pressure. 

#FOAMED of the Week: Get Plastered - via LITFL

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If ever (in desperation) you resort to Googling your patient's symptoms in search of a diagnosis, you will soon discover Life in the Fast Lane, Australia's gold mine of everything ED and critical care.  #FOAMed to the core, they have been developing Online Meducation for years.

Last week they put up a selection of videos going through some of the common casts we do in the ED. Perfect as a wee refresher, but also useful if you're just starting your ED rotation.....not looking at anyone in particular......

Obviously there's sometimes some local variations but this gives a great starting point for learning the practical skills involved in managing fracture in the ED.

Viva la #FOAMed! Videos Below:


Trauma in the Elderly, its not only HECTOR that cares....

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Of the 64 billion people living in the UK, about 11 million are over 65. As an expanding demographic, we see more of this population in the ED than ever before. 

Now arguably becoming the bread and butter of our day to day work, the spotlight is being turned on how we can do better in the management of trauma in the elderly. 

The HECTOR (Heartlands Elderly Care Trauma & Ongoing Recovery, @HECTORcares) Project seeks to improve our understanding of trauma and how to apply it in the the elderly population. They are starting to run courses of the next few years and have released the first 6 chapters of the course manual on www.heftemcast.co.uk.

The emphasis is simple - trauma care needs to be patient centred. Designing systems to be patient centred is unfortunately a nightmare so its up to us as clinicians to make sure its done right. We have to Care!

Check out the website for more info on the project including podcasts with its founder Dr Dave Raven. 

Plus check out the first 6 chapters of the course manual below: 

Chapter 1 – An Introduction to HECTOR

Chapter 2 – Triage

Chapter 3 – The Primary Survey

Chapter4 – Imaging after the Primary Survey

Chapter 5 – The Secondary Survey

Chapter 6- The Silver Survey

EM #FOAMed Bootcamp

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#FOAMed Induction Resources for Emergency Medicine.

Starting your first job in the Emergency Department may seem a little daunting. Be re-assured, there is always senior support available to you on the shop floor - never be afraid to ask for help!

But if you want to go that extra step to prepare there's an amazing amount of help available online - Free Open Access Medical education- #FOAMed. 

We wanted to signpost some of the amazing #FOAMed resources at your fingertips, as well as highlight learned - the meducation part for Edinburgh Emergency Medicine's Website.

 

Welcome to Emergency Medicine! #GetLearnED 

 

Check out Manchester's St Emlyns Blog Induction Podcasts: 

Vodcasts/podcasts from The Royal College of Emergency Medicine's FOAMed Network:

Southampton Emergency Medicine Education Project: SEMEP

#FOAMed of the Week: New ACC/AHA Cardiac Arrest Algorithm via R.E.B.E.L EM

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R.E.B.E.L. EM stands for Rezaie’s Evidence Based Evaluation of Literature in Emergency Medicine.  Salim Rezaie is Clinical Assistant Professor, Emergency Medicine & Internal Medicine University of Texas Health Science Centre at San Antonio. 

In a guest post the REBEL EM crew discuss the the new guidelines from the American College of Cardiology/American Heart Association on cardiac cath after arrest. These were recently published online ahead of print: J Am Coll Cardiol. 2015;66(1):62-73. doi:10.1016/j.jacc.2015.05.009. 

Here is the ACC/AHA algorithm: 

As ever in the #FOAMed world you have to remember context of the material you are reading. This is obviously produced for the US health system, and as such some aspects may not translate directly into UK practice. It is however an excellent summary of the evidence around cardiac cath after OOHCA.

Familiarity with the evidence is essential if we are to advocate for the best possible care for our patients.

 

#FOAMed of the Week: John Hinds

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The late john Hinds was a consultant anaesthetist/ICU doctor, pre-hospital doctor and motorsports medic in Ireland. Over recent years he gave some inspirational, educational and hilarious talks all over the world, memorably at SMACC Gold and SMACC Chicago. 

Sadly he recently died while providing medical cover at a skerries 100 practice session.

I've put together a collection of some of the various talks and podcasts he did across the #FOAMed world to highlight his brilliant contributions to pre-hospital,  trauma and critical care education. 

My thoughts are with his family at what must be a difficult time. 

emcrit.org podcast podcast 153 with john hinds on critical care: 

HTTP://RESUS.ME/BE-LIKE-THAT-GUY-DR-JOHN-HINDS/

http://www.rcemfoamed.co.uk/portfolio/john-hinds-on-airway-at-rcembelfast/

emcrit.org podcast 135 with john hinds on trauma care: