This month we have a podcast on how we approach patients with mental health needs in the ED. It outlines the rationale and delivery of a change in how we manage some of the most vulnerable patients in the ED. We hope you find it interesting and I suspect you will also find it quite challenging. We are aiming to improve the care of patients with Mental Health needs, but in doing so we must face our own prejudices and practices, which are not always healthy.
Editorial note on language – as you listen to the podcast you might be surprised to hear us use words like ‘insane’ in relation to decisions and systems. In some ways it seems incongruous to use such terms in a podcast that promotes a better understanding of mental health issues. We considered taking them out, but after consideration we left them in an attempt to illustrate the false dichotomy between medical and psychiatric needs that is embedded in much of our work. Perhaps the use of language reflects this and makes the point that we can do better.
Why do we need to rethink our approach to Psychiatric emergencies in the ED?
There are a group of life threatening conditions that present to your ED that you don’t deal with, or at least you don’t deal with very well. This group of conditions has a significant mortality and an incredibly high morbidity, but if you are a typical emergency physician you probably don’t think you own the problem. This group of conditions is at least as common as chest pain and yet it’s unlikely that you feel the same level of ownership of the problem.
The issue is of course that of psychiatric illness. In Virchester it accounts for about 1 in 20 patients through the door, and that number is much, much higher if we were to include substance abuse and its related outcomes.
In general, the approach in many UK units is to divide the patient up on arrival into physical and mental health needs. We feel responsible for the physical problem and then we try and offload any psychiatric problems onto the psychiatrists and mental health teams. At the centre of this is the patient who really does not see or feel this dichotomy and we really need to challenge our approach to this.
Such dichotomies are embedded in our systems. I’m sure that many readers will be familiar with the request to ‘medically clear’ a patient in order that they can then be assessed by the mental health team. Bizareer customs and practice take place around these assessments, for example in Virchester the rule that a patient with a heart rate of more than 100 cannot be medically fit for assessment is sometimes used to decline psychiatric assessment. Such informal rules (none are actually written down or appear in any agreed protocol) result in delayed assessments, patient distress and long waits in the ED. I could go on, and whilst there is good and practice amongst all teams and specialities (we are just as bad at the mental health teams in promoting this dichotomy), the point is that we really don’t act in the patient’s best interests by dividing mental and physical health.
This clear difficulty was one of the starting points for the APEX course, which aims to bring psychiatry and emergency medicine together for the benefit of patients, services and staff.
The interview on the podcast is recorded with Prof. Kevin Mackway-Jones who many of you will know through his work with the Advanced Life Support Group. He was the instigator of APLS at a time when there was a clear need for emergency physicians to improve their approach and knowledge of paediatric emergencies. APEx feels the same. A common condition in our EDs for which we are not currently doing the best that we can for our patients and where a joint teaching and learning approach is needed between the ‘tribes’ of medicine.
This could be a game changer to how we manage a very common and very vulnerable group of patients in the ED.
So what’s on the course?
I can’t give you the whole courses here but there are a few principles that underpin the content and approach.
- It’s co-written and developed between psychiatry and emergency medicine
- It’s a symptom based approach (just like APLS) and so it deals with how we deal with the presenting complaint first and not the underlying diagnosis (as you may not know what this is when you are dealing with the patient).
- The approach will be familiar to many Eps.
- Primary Survey
- Secondary Survey
- Definitive management
- There is a unified approach. The patient needs an ABC approach for physical health, but in addition and concurrently they also need the AEIOU approach.
- A – Assessment of Aggression and Agitation
- E – The Environment in which you are assessing the patient
- I – The Intent of the patient
- O – The Objects the patient has to carry out the intent
- U – The Unified assessment (as you will also be carrying out an ABC assessment alongside AEIOU)
- Rapid tranquilisation is a key conern for EPs and so there is lots on this that does not automatically default to restraint, a needle and syringe and a significant risk.
- Oral tranquilisation works
- Ketamine is not the answer to every patient
- It’s a risk based approach as every intervention (including no intervention) has a risk
Find out more
You can find out more on the ALSG website here.
What has APEx got to do with St Emlyn’s?
At St Emlyn’s we are letting you know about the course for several reasons. Many of us teach and support the work of the ALSG charity (for free and because we believe in it), but also that we all believe that the care of patients with mental health needs can be improved. They are a vulnerable group who generally get a bad deal when they present in crisis to emergency departments. We know we can do better and we believe that this course will help us achieve our goal to do the best that we can for our patients.
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Simon and Iain talk through what the team has been up to in April. All the blogs should be on the website and of course you can subscribe to the podcast via iTunes or via PodBean.
Key publications in April.
1. Our e-book on health and wellbeing for the resuscitationist. http://stemlynsblog.org/the-resuscitationists-guide-to-health-and-wellbeing-a-st-emlyns-e-book/
2. Police drop offs for penetrating trauma in the US. http://stemlynsblog.org/to-protect-and-serveand-drop-off-st-emlyns/
3. The latest blogs on the amazing #badEMfest18 conference in South Africa http://stemlynsblog.org/bademfest18-day-3-st-emlyns/
4. The top 10 trauma papers of the year http://stemlynsblog.org/top-10-trauma-papers-2017-2018-for-traumacareuk-conference-st-emlyns/
5. Complications of anticoagulation http://stemlynsblog.org/complications-of-anticoagulation-and-how-to-manage-them-st-emlyns/
6. Trauma CT in kids http://stemlynsblog.org/jc-trauma-paediatric-wbct/
7. The folly of dichotomous diagnosis http://stemlynsblog.org/50-shades-black-white-folly-dichotomy/
8. Bonded in Blood with Ashley Liebig and Noah Gallagher http://stemlynsblog.org/bonded-in-blood/
9. How to coach your team and the Austrian EM conference http://stemlynsblog.org/how-to-coach-feedback-team-st-emlyns/
Gosh, when you write it down and think about all the work the rest of the team puts in to teach and learn it makes me kind of proud. Don't forget to join us later this year for the live version at #stemlyneLIVE in Manchester.
Iain and Simon catch up on what happend on the St Emlyn's blog and podcast in March 2018.
Visit http://www.stemlynsblog.org for more info and links to the articles mentioned in the podcast.
This month we cover IV fluids and the never-ending debate around balanced crystalloids vs. saline, we look at working in Africa on secondment or as a placement and we round off with a discussion of the utility of pupillary signs in the prognosis of patients post cardiac arrest.
The Physician Response Unit (PRU) is an innovative service in East London that takes the emergency department to the patient. The PRU is led by Tony Joy, consultant in emergency medicine and prehospital care and is a fairly unique service to the UK.
In this podcast our very own Richard Carden interviews Tony for an in depth understanding of how the service is supporting the entire emergency care system in London.
You can read more about the PRU here https://londonsairambulance.co.uk/our-service/news/2017/10/remodelled-pru-to-be-a-seven-day-service-for-the-first-time and look out for a blog post on the St Emlyn's blog site very soon.
Iain and Simon review the best of the blog from February 2018.
Iain and Simon round up the blog posts from January 2018. You can listen to the podcast below. Links to all the blog posts mentioned are listed below.
January 1, 2018 0 Comments As 2017 ends and we look forward to 2018 it’s time to reflect on a year with the St.Emlyn’s team. Despite our chronological and geographical dispersal it’s really felt like a team effort in 2017. We have travelled, learned, listened,…
January 4, 2018 3 Comments Social media can sometimes give the impression that all is rosy in the world of resuscitation. We hear of the amazing saves, the wonders of ECMO, helicopters and heroic acts with great outcomes, but the reality is of course very…
January 9, 2018 0 Comments It’s the second time I’ve been to the Northern Emergency Medicine conference, this year held in the sunny city of Durham. I say sunny… I needed my jacket. Last year’s programme was great and included some fantastic speakers, including our…
January 12, 2018 4 Comments Last month, I came across a clinical review published in the Annals of Emergency Medicine1 that got me really excited! It got me excited (in a geeky professional sense of course…) as it covered a topic that causes significant…
January 16, 2018 3 Comments On Reflection I’ve been reflecting on reflection for some time now, at least since I started formally collecting my lessons from Sydney HEMS and probably even before that, because this sort of meta nonsense is something medical education enthusiasts like…
January 21, 2018 2 Comments You might be aware that an exciting new trial has started called Cryostat-2. This is exciting as it has the potential to improve patient outcomes, but also because it will involve all the Major Trauma Centres in England and 8…
January 22, 2018 4 Comments So another year, another Critical Care Reviews meeting. Rob is doing an absolutely fantastic job with these, inviting lead authors from major critical care trials to present and defend their work. In fact, this is going so well that this…
January 28, 2018 0 Comments Last weekend, the BeSEDiM (Belgian Society of Emergency and Disaster Medicine) organised their annual symposium. It is the scientific organization of the Belgian emergency physicians with Said Idrissi as chairman. 13 years ago, Belgian Emergency medicine was born as a…
January 29, 2018 0 Comments This is a guest post from our good friend Stevan Bruijns aka @codingbrown Stevan has been an advocate of international emergency medicine for many years and he, like us feels that there is much that high income countries can do…
Before you go please don’t forget to…
- Subscribe to the blog (look top right for the link)
- Subscribe to our PODCAST on iTunes
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- Find out more about the St.Emlyn’s team
Simon and Iain belatedly reflect on a tough winter and the posts in January.
Check out stemlynsconference.com if you want to know more about #StEmlynsLIVE
In this episode, the fabulous Liz Crowe (@LizCrowe2) discusses how to approach debriefing after critical (and non critical) incidents in healthcare. We focus on the debriefing that takes place 5-7 days after an incident. For more on a "hot" debrief listen to this podcast by Ashley Liebig and Rob Orman (http://blog.ercast.org/beating-stress-and-the-hot-offload-with-ashley-leibig/)
In this podcast Simon talks to Dan Harvey (ITU) and Mark Wilson (Neurosurgeon) on the management of complex patients with a perceived devastating brain injury.
This podcast is linked to the blog on the St.Emlyn's website.
December round up of St.Emlyn's
Dates for your diary.
3.The ED Spa. Wellness and Support in #Virchester. St.Emlyn’s. (NOTE - We forgot to mention the incredible contribution of Kirsten Ballantyne on this project - it's more than just Laura)
If anyone wants to know more about any of the conferences we talk about please get in touch with the team firstname.lastname@example.org
Natalie and Simon discuss reflections, e-books and life at Sydney HEMS. This week we have added Lorikeets in the background (Nat recorded at Coogee Bay in NSW). We think they sound cute so we've kept them in (or rather we could not edit them out).
A quick summary on how you can use group messaging systems in a major incident. A vast improvement on telephone cascades BUT you have to set this up in advance. If you make it up on the day it will be a disaster. Here's the tips and tricks from the Virchester team. You can read more here http://stemlynsblog.org/tag/whatsapp/
Simon (@EMManchester) and Iain (@docib) review some of the articles from the St Emlyns blog site (http://stemlynsblog.org/) from recent weeks and chat about the current state of Emergency Medicine in the UK.
1:00 - How to declare a Major Incident - http://stemlynsblog.org/how-to-declare-a-major-incident-st-emlyns/
3:10 - RCEM ASC 2017 – Update on the TiLLI study - http://stemlynsblog.org/rcem-asc-2017-update-on-the-tilli-study/
6:03 - The rise and SURPRISE of the DOACs - http://stemlynsblog.org/the-rise-and-surprise-of-the-doacs/
8:08 - Life as an EM Trainee in South Africa - https://itunes.apple.com/gb/podcast/the-st-emlyns-virtual-hospital-podcast/id547326956?mt=2&i=1000393179333
9:26 - Rheum for Improvement? The physical challenge of EM training - http://stemlynsblog.org/rheum-for-improvement-st-emlyns/ Harriet's website is here - https://www.rheumforimprovement.com/
10:47 - JC: Oxygen in ACS. A fuss about nothing? The DETO2X Trial - http://stemlynsblog.org/oxygen-in-acs-a-fuss-about-nothing/. Paper is here - http://www.nejm.org/doi/full/10.1056/NEJMoa1706222
11:57 - Is cMyC the new troponin? - http://stemlynsblog.org/cmyc-new-troponin/
13:00 - Who gets a Tetanus? You get a Tetanus! - http://stemlynsblog.org/tetanus-in-the-ed/
14:22 - Mass Casualty Incidents: Lessons from AAST - http://stemlynsblog.org/mass-casualty-incidents-lessons-aast-st-emlyns/
15:00 - The Annual Scientific Conference and the State of EM
I recently met up with some amazing UK docs working in South Africa at the EMSSA conference. This conference was held in Sun City near Johannesburg and brought together emergency physicians from across the contient.
It was great to catch up some UK docs who were on postgraduate electives working in hospitals like Khayelitsha which you may remember from this amazing blog by Robert Lloyd.
So please listen, learn and get in touch if it's something that you want to do.
On the podcast we have
Simon Carley (@EMManchester), Jennifer Hulse (@coffeeheadaches), Chris Wearmouth (@CCWearmouth), Jacob Smith (@DrJacobSmith), Emma Gold (@EmmaRGold) and Chloe Sanderson.
There are also Marina Queisser & Eveline Baerends in the photo.
It's that time of year again, where we get new colleagues in the Emergency Department (and across lots of other areas of the hospital too).
These are some of the top tips for new starters (and life in the ED in general) gathered from the senior medical and nursing team at Virchester (South).
More induction guidance and education available at http://stemlynsblog.org/induction/
Oh. And one tip we left out - always wear sunscreen.
With thanks (and apologies) to Baz Luhrmann.
Our last podcast from the teaching course in Copenhagen #dasTTC. George Wills, Simon Carley, Natalie May, Jesse Spurr and Salim Rezzaie give the faculty perspective.
The short version is we think and hope that the delegates learned something, but as a faculty we once again learned loads and met some amazing people.
Roll on the next course. (hint they are in San Fransisco and Melbourne).
Iain and Simon chat through our top ten trauma papers for 2016. Lots here for anyone who is interested in trauma including whole body CT, traumatic cardiac arrest, neurosurgery in severe head injury and much more. As ever we'd suggest you read the original papers, references for which along with a blogpost can all be found here http://stemlynsblog.org/top-10-trauma-papers-2016-st-emlyns/
In a new podcast format Simon (@EMManchester) and Iain (@docib) discuss the month's offerings from the St Emlyn's blog and podcast (www.stemlynsblog.org).
It's been a month full of interesting posts on subjects as diverse as Thrombolysis in Stroke (Alan Grayson), The Future of Emergency Medicine in the Social Age (Simon), Cardiac Arrest Centres (Simon), Love in Critical Care (Liz Crowe), Transfers (Nat and Simon), Thrombolysis in PE (a guest post from FOAMed legend Anand Swarminathan) and Benzos in Back Pain (Janos). Head to the website for the articles themselves and all the references and links you need.
We're aiminig to make this a regular monthly podcast - let us know if it's useful and enjoyable and how we could make it even more educational.
This podcast accompanies the St.Emlyn's blog post on top tips for chest drainage.
A quick round up of events from the excellent Teaching Course in New York (https://flippingmeded.com/) with guests Ross Fisher (@ffoliet), Ashley Leibig (@ashleyliebig), Sandra Viggers (@StarSkaterDK) and Camilla Sorenson (@Camillabirgitte).
For brilliant summaries of each day, with details from every talk, visit http://scanfoam.org/teaching-course-nyc-day-1-ttcnyc16/ (Day 1) and http://scanfoam.org/teaching-course-nyc-day-2-ttcnyc16/ (Day 2)
The fabulous Liz Crowe (@LizCrowe2) returns to the St Emlyn's podcast to chat with Iain about how we can communicate more effectively with children in critical care. This podcast explores topics that are important not just for clinicians, but anyone who works with or has children.
Iain Beardsell, Simon Carley and Roger Harris catch up in Vienna to give you the back story on DAS SMACC, registtion and speakers.
Simon and Iain chat about the first few days at EuSEM in Vienna. Some of the clinical and social highlights. We also have a bonus podcast at the end recorded with a volunteer at Iain's "Podcasting for Beginners'" talk. For more from EuSEM (The European Society for Emergency Medicine) congress follow the #eusem16 hashtag on Twitter.
As part of our induction series we look at the management of upper GI bleeds in the ED.
Rick and Simon talk blinding (and masking) for your critical appraisal delight.
Robert Lloyd aka @ponderingEM from the Pondering EM blog joins Simon to talk about his experiences in a South African ED. This is an amazing tribute to the work our South African colleagues and how an Englishman found a way to adapt to the challenges (and there are many) of SA EM practice.
Iain and Liz discuss boundaries and medicine. What do you do when your personal life impacts on your clinical practice.
Ross Fisher, consultant paediatric surgeon and lead for TARNlet joins Simon Carley at the London Trauma Conference to discuss the challenges in managing paediatric trauma in the UK.