EMJ Blog – Should More Emergency Physicians be ‘Piloting British Airways’? – The Musings of a Trainee


I’ve written a second piece for the Emergency Medicine Journal Blog which I’m very excited about.

The post tackles a fairly controversial issue in the UK – the role of EM doctors in emergency airway management. The ‘ED-RSI’ landscape over here is very different to Australia and the US, and my hope is that the piece will stimulate some positive discussion, and hopefully contribute to some overdue culture-change in British hospitals.

The post was published on the blog earlier today, check it out by clicking here.

I hope you enjoy!

Robert Lloyd

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Futureproofing EM: Why your trainees deserve it (and your nation needs it). St.Emlyn’s

St.Emlyn's – Meducation in Virchester #FOAMed

I suspect all Deaneries (locality branches of Health Education England as they are now known) have their traditions and meetings. In the former NW post-graduate deanery we have ours. One of these is Calman day. Until this year it was…
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CLINICAL HANDOVER: from “Me” to “You”

In a busy emergency department, there are days when all the beds are occupied by patients and your emergency gates are flooded with incoming patients; your duty is about to start and the scenario is overwhelming. You are anxious to know every essential detail of each patient before you take over the responsibility. Clinical handovers are an important responsibility of every Emergency Physician. Handovers can range from ED physician to ED physician during shift change, ambulance doctor to ED physician, ED physician to an intensivist during patient transfer. ED physician should be well versed with giving as well as receiving a thorough, concise, handover for benefit of patient, hospital and self.
A clinical handover is defined as ‘the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis.’ (1)
A good handover forms essence for continuity of patient care. It involves effective communication, clinical documentation, transfer and referral notes and discharge documentation. In India, clinical handover is one of the least researched topics; more so, there is no defined pattern or checklist that is used by doctors while giving handover.

Medical errors are the third leading cause of death after heart diseases and cancer in the USA. Communication errors form major cause of up to 70% of sentinel events, out of which 62% major factor was change in shift. There are multiple parts of a handover where important information may be dropped or not conveyed. This can affect patient care, length of stay, and department flow.
A survey carried out by Kessler et al among 41% of ACGME accredited EM residency program; 56.6% of EM physicians responded that they do not use standardized handoff.

In the USA, handovers are in the form of sign-outs. The format used for sign outs could be verbal, written or digital. One of the sign-out strategies used is called ANTICipate. It consisted of
  • Administrative data (Name, age, sex, bed no, admission status);
  • New Information (chief complaints, brief history, differentials, medications, allergies, current baseline status, recent significant events/procedures);
  • Tasks (what needs to be done, if-then approach);
  • Illness (How sick is the patient/ triage category);
  • Contingency plan (what may go wrong/ what to do about it, what has/has not worked before, difficult family/ psychosocial situation)
The Joint Commission in 2006 introduced a standardized approach to handover: the SBAR method (3). The SBAR approach consists of situation, background, assessment and recommendation. Only the most relevant data is included and put together in SBAR frame and presented effectively to the incoming team who is also well versed with the approach. Then, specific questions may be asked to clarify and confirm the handover. SBAR is generalized and can be used for all kinds of patients. This should be followed by ‘read back’ or ‘repeat back’. In ‘read back’, the receiving team repeats the important information, so there is a closed loop communication.

  • Situation:Mr. Kapoor has fever with chills and petechial rash.
  • Background: His symptoms started 3 days back. His temperature is 102, heart rate of 100/min and BP 130/80. He has no co-morbidities. His platelet count is 1lakh. Now, he has generalized weakness.
  • Assessment: My assessment of the situation is he has acute febrile illness most likely dengue.
  • Recommendation: I recommend we hydrate him well, bring down his fever, trace the Dengue report and keep watch on his platelet count and admit him on floors under Dr. ABC.
A specific handover technique for trauma patients is IMIST-AMBO. IMIST-AMBO stands for
  • Identification/Introduction,
  • Mechanism of Injury/Medical complaint,
  • Injuries/Information related to the complaint,
  • Signs and Symptoms,
  • Treatment given/Trends noted,
  • Allergies,
  • Medications,
  • Background history and
  • Other information.

There must be a crossover of two shifts. Adequate dedicated time must be allowed for handover. Handover must be given as a team, consisting of team leader, junior doctors and nursing staff, so everyone is on same page and clarifications can be done, if needed.

Sufficient and relevant information should be exchanged to ensure patient safety so that the senior doctors have knowledge of the triage category 1 and 2 patients; junior doctors of the team are adequately briefed on concerns from previous shifts and tasks not yet completed are clearly understood by the incoming team.

It decreases morbidity and mortality of patients because of greater continuity of care. Patients don’t like repeating the history again and again to each health care provider. A good handover prevents repetition, improves patient satisfaction. Patient’s perception of professionalism is reaffirmed and improved.

Professional protection: Clear and accountable communication can protect against wrongful attribution of responsibility for errors that occur.

Reduction of stress: feeling informed and having up to date information enables doctors to feel more confident in patient’s care. Doctors have found that handover can be a useful experience that gives them the opportunity to involve appropriate specialties early, for example intensive care. There is ability to discuss cases with other specialties in an open environment.

Educational: handover provides development and practice of communication skills and a well-led handover session provides a useful setting for clinical education

Job satisfaction: providing the best possible quality of care is highly rewarding and is fundamental to a doctor’s sense of job satisfaction

In a busy ED, there could be lots of disturbances, interruptions and distractions that can prevent a good handover. Handover should have dedicated time except for life-threatening emergencies.

Not everybody is well versed with a common handover scheme. Each hospital should develop their own handover checklist and have role plays to make a conscious effort in reducing errors and delays.

Handover should be carried out as team instead of hierarchical handovers (ie junior doctors to junior doctors and so on). Team debriefing helps in better patient care, prevents delays and minimizes errors. It also makes handovers- a teaching tool.

Take Home Points  
  • Use a checklist like SBAR for transferring information from one team to other along with ‘read back’.
  • Handovers as team can have better continuity of care.
  • Simulate handover technique to become well versed at it.  
  • Use the dedicated handover time as a teaching tool.

  1. National Patient Safety Agency, London. As cited in Safe Handover: safe patients. British Medical Association, London, pg 7.
  2. Fassett, R G & Bollipo, S J. Morning report: an Australian experience. Medical Journal of Australia 2006; 184: 159-161.
  3. Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care 2010;19:493–7
  4. Sujan, Mark, et al. “Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research.” (2014).
  5. Kessler C, Shakeel F, Hern HG, Jones JS, Comes J, Kulstad C, Gallahue FA, Burns BD, Knapp BJ, Gang M, Davenport M. An algorithm for transition of care in the emergency department. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine. 2013 Jun;20(6):605.
  6. Kessler C, Shakeel F, Hern HG, Jones JS, Comes J, Kulstad C, Gallahue FA, Burns BD, Knapp BJ, Gang M, Davenport M. A survey of handoff practices in emergency medicine. American Journal of Medical Quality. 2014 Sep 1;29(5):408-14.
  7. Hern H, Gallahue FE, Burns BD, Druck J, Jones J, Kessler C, Knapp B, Williams S. Handoff Practices in Emergency Medicine: Are We Making Progress?. Academic Emergency Medicine. 2016 Jan 1.
  8. Stokowski LA. Who Believes That Medical Error Is the Third Leading Cause of Hospital Deaths?. Medscape, May. 2016 May 26;26.
  9. WHO Collaborating Centre for Patient Safety Solutions. Communication during patient hand-overs. Patient Safety Solutions. 2007; 1:solution 3.
  10. Committee on the Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2004:45.
  11. Committee on the Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000:36.

Nikhil N. Tambe – @nikhil16mar

Emergency Medicine Resident (PGY-2)
Masters in Emergency Medicine (GWU)
Kokilaben Dhirubhai Ambani Hospital, Mumbai
Instructor (American Heart Association)
Lifesupporters Institute of Health Sciences, Mumbai

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July Trauma MedEd Newsletter Topic: Field Amputation

This is probably one of the worst calls a trauma surgeon can get: “Please dispatch a surgeon to the scene. We need a field amputation to extricate the patient.”

For trauma professionals in any discipline, this is probably a once in a career event. And for that reason, there is likely to be a lot of confusion.

The next newsletter will cover this topic in detail. Topics include:

  • Statistics on how often field amputation is needed
  • Indications for the procedure
  • Logistics: getting to the scene and staying safe
  • Essential equipment
  • Sample policies
  • And more!

If you haven’t already, subscribe to my Trauma MedEd newsletter so you can get this edition when it’s released on September 1. Otherwise, it will be released here later in the month.

Click here to subscribe and download back issues!

Source: http://regionstraumapro.com/

The Art and Science of Extubation

Lloyd Roberts presents a comprehensive overview of the ‘art and science of extubation’ in the intensive care unit. This video lecture is a resource used for the Critically Ill Airway course.

Additional useful resources from the LITFL CCC include:


This video lecture on ‘Extubation of the Difficult Airway’, by airway expert Keith Greenland, is also highly recommended:

Finally, the brief videos shown below, by AirwayOnDemand, show the use of an airway exchange catheter post-extubation:

The post The Art and Science of Extubation appeared first on INTENSIVE.

Source: Intensiveblog

#FOAMed of the Week: Amputation via @PHEM_cast

Pre-hospital Amputation thankfully doesn’t happen very often. When it does there isn’t likely to be time to google it….

Thinking the procedure through and getting to know the equipment is essential to keeping a cool head when the adrenaline is pumping.

PHEMCast have put together a great podcast which can guide you through the procedure and get you started.

Check out the website for other PHEM podcasts or subscribe on your podcast manager.

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Trick of the Trade: Paraphimosis – Pour Some Sugar On Me

paraphimosisParaphimosis occurs when a retracted foreskin can’t be reduced back over the glans of the penis. Risk factors for paraphimosis include scarring, vigorous sexual activity, chronic balanoposthitis, and forgetting to replace the foreskin after catheterization or manipulation.

Paraphimosis can be a urological emergency as the tight ring formed by the foreskin can cause ischemia to the tip of the penis and eventually gangrene. Timely reduction is of high importance. Treatment involves gentle compression of the glans and gradual manual foreskin retraction.1 Unfortunately, as time goes on, more swelling occurs making traditional reduction techniques more difficult.

Trick of the Trade

Sugar solution for non-reducible paraphimosis

  1. Mix 50 mL of 50% dextrose solution with 2% lidocaine jelly (a.k.a. Urojet®).
  2. Place a gauze into the solution.
  3. Place soaked gauze on the glans of penis.
  4. Cover with condom or condom foley.
  5. Wait 1 hour.
  6. Reduce the paraphimosis.

The high solute concentration of the sugar water pulls the water from the swollen tissue while lidocaine provides topical analgesia. This technique has been described on ALiEM for a case of rectal prolapse and in a 1998 case report.2


This may be an easy and cost-effective means of reducing a paraphimosis in the emergency department. The downside is that the treatment requires at least an hour for the swelling to come down. In a letter describing this technique, Dr. Coutts writes his recipe: “a degree of patience on behalf of the surgeon and patient.”3 This trick of the trade worked for our patient who was able to avoid more invasive procedures like a dorsal penile block and a dorsal slit incision.


Image credit

Little B, White M. Treatment options for paraphimosis. Int J Clin Pract. 2005;59(5):591-593.[PubMed]
Kerwat R, Shandall A, Stephenson B. Reduction of paraphimosis with granulated sugar. Br J Urol. 1998;82(5):755.[PubMed]
Coutts A. Treatment of paraphimosis. Br J Surg. 1991;78(2):252.[PubMed]

Author information

Jonathan Fu, MD

Jonathan Fu, MD

Emergency medicine resident
UCSF-San Francisco General Hospital EM Residency Program

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What is a Hydrocoele of the Spermatic Cord?

Patient Presentation
A 54-day-old male came to clinic after his parents noticed a lump in his left groin the prior evening while giving him a bath. They said that it did not appear to bother the patient, had not changed in size nor had any color changes since they had noticed it. He had not been ill. They denied any fevers, rashes, scratches, nausea or emesis. The past medical history showed a term infant without complications. The family history was negative for anatomic genitourinary problems or cancer. The review of systems was negative.

The pertinent physical exam showed a smiling infant with weight in the 50% and normal vital signs. A 1×1.5 centimeter firm mass was noted in the left groin. It was located medially to the inguinal canal. It appeared be aligned with the spermatic cord and move with it. It could not be transilluminated and was not physically pulsatile. Both testes were palpable in the scrotum with normal alignment. Both testes were the same size bilaterally and hydrocoeles were noted in the scrotum bilaterally. There were no diaper rashes, other rashes or skin changes on the legs or groin. The examination was otherwise normal.

The diagnosis of an inguinal mass was made and the resident and attending pediatrician considered that this could be an inguinal hernia or lymph node but the location and mass characteristics didn’t appear to be as consistent. A hydrocoele was also considered but the mass was in the inguinal area and not in the scrotum. A soft tissue tumor was considered but seemed again unlikely because of age. Anatomic variations of the vasculature or vas deferens were considered and seemed more consistent because of the location. The radiologic evaluation of an ultrasound found the diagnosis of a hydrocoele of the spermatic cord. The attending pediatrician was surprised as she had not seen this variation of a hydrocoele in her clinical practice. The patient was referred to pediatric surgery and was being monitored for resolution.

Case Image

Figure 119 – Longitudinal ultrasound image thorough the inguinal canal (to the left of image) and the scrotum (to the right of image) shows a cystic structure within the inguinal canal consistent with a spermatic cord hydrocoele. Within the scrotum is the normal epididymis and testicle and a small hydrocoele.

Hydrocoeles are common anatomic variations caused by the incomplete obliteration of the processus vaginalis. The processus vaginalis is a peritoneal remnant that follows the testis and spermatic cord into the scrotum as the testis descends into the scrotum during development. As the processus vaginalis traverses from the testis back to the peritoneum, a hydrocoele can occur at any point along its length. The obliteration of the processus vaginalis occurs with the closure at the internal inguinal ring, followed by closure just above the testes with atresia of the area in between. The closure of the area around the testes itself is often not complete by the time of birth and hydrocoeles are commonly seen in the scrotum; most resolve by 1 year of age. The hydrocoeles may be uni- or bilateral.

Learning Point
Hydrocoele of the spermatic cord (HSC) is a uncommon variation of hydrocoele. There can be a chronic or acute onset of swelling in the upper groin or inguinal area above the testis and epididymis. HSC is divided into 2 or 3 types depending on the author.

  • An encysted HSC occurs when there is obliteration of the processus vaginalis at both ends with solitary cyst formation. This does not change in size.
  • A funicular HSC occurs when there is obliteration of the processus vaginalis distally leaving open the proximal processus vaginalis to communicate with the peritoneum. This may change in size because of differing amounts of peritoneal fluid in the cyst.
  • A mixed HSC has a proximal opening of the processus vaginalis but has an integrated wall around the cyst that causes it to act like a encysted HSC. It does not change in size because the wall prevents fluid from entering the cyst. These types of cysts can be solitary or multiple.

HSC is usually treated by pediatric surgeons and treatment may be watchful waiting if there is a funicular HSC up to around 1 year of age after which it is repaired. If there is an encysted HSC or there appears to be a related inguinal hernia then surgery is usually recommended earlier. HSC torsion can occur but is very rare. In one study of HSC, 30% of patients had anatomic inguinal defects on the contralateral side.

Hydrocoeles have been known to the medical profession for hundreds of years. In an 1843 article, Dr. Robert Liston describes encysted hydrocoeles:

    “I. On the testicle, betwixt the albuginea and tunica vaginalis – at first as transparent cysts, but gradually increasing in size.

    II. As presenting by the side of the epididymis, betweixt that body and the reflection of the processus vaginalis from the testis.

    III. As appearing in the course of the spermatic chord above the testicle. In this latter situation, no doubt, collections of various kinds are to be met with in the loose filamentous tissue of the chord; in the unobliterated portions of the spermatic process covering that body; or possibly, in more immediate connexion with the vas deferens itself.”

Questions for Further Discussion
1. What is the differential diagnosis of testicular pain? For a review click here
2. What is the differential diagnosis of scrotal swelling? For a review click here
3. What is the differential diagnosis of vulvar masses? For a review click here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Testicular Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Liston R. A few observations on encysted hydrocele. Med Chir Trans. 1843;26:216-22.

Chang YT, Lee JY, Wang JY, Chiou CS, Chang CC. Hydrocele of the spermatic cord in infants and children: its particular characteristics. Urology. 2010 Jul;76(1):82-6.

Senayli A, Senayli Y, Sezer E, Sezer T. Torsion of an encysted fluid collection. Scientific World Journal. 2007 Apr 9;7:822-4.

Rathaus V, Konen O, Shapiro M, Lazar L, Grunebaum M, Werner M. Ultrasound features of spermatic cord hydrocele in children. Br J Radiol. 2001 Sep;74(885):818-20.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

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Old Dog, New trick… teaching procedural skills

The news this week for me – I learned a new procedure!  Yes, after many years of doing things that I had learned and practiced I found myself in the situation where I could have a crack at something new.   This was an interesting experience for me because :-

  1. It has been a while since I tried to do something unfamiliar.
  2. It was an interesting exercise as a teacher to go back to being the novice, to feel the pressure of that moment.
  3. There is something deeply satisfying about acquiring a new arrow in one’s skills quiver
  4. I learned [from the inside] about how to better teach practical procedures.
  5. I was on the awkward side of the tension between letting the novice “have a go” and yet keeping the patient safe.

So what was this new skill?  I learned how to perform a subtenon eye block.  This is a relatively simple anaesthetic technique that appears to be quite dangerous and painful, but is actually not so bad.  If you want to see it in action… check out this clip from UltrasoundBlock.com [edit: no ultrasound required!].  Simple enough to do, but requires the use of unfamiliar instruments, in a very sensitive part of the body with a patient whom is wide awake.

The big difference between my learning this skill and the previous learning in procedures such as epidurals etc [aside from about 15 years] was that I had a mental structure as to how I was going to make the most of my mentor’s availability to teach.  Having been exposed to the SETT UP technique, and trying to use it with my students it was great to be able to apply it to myself.

I basically used the 5-step technique described by George and Doto in 2001, with a bit of a FOAMed twist.  Here is the five-stage approach:

  • Conceptualisationthe learner must understand why it’s done, when it’s done, when it’s not done, and the precautions involved.

This can be pulled from any anaesthesia or ophthalmology textbook.  There is a list of indications, contraindications and the stuff you need to tell the patient before performing the procedure.  Review the basic sciences.  Anatomy is important to review as this is not an area most ED docs have to contemplate often.

  • Visualisationthe learner must see the skill demonstrated in its entirety from the beginning to end so as to have a model of the performance expected.

This is where FOAM comes in  – one can watch dozens of videos.  I watched it done by multiple practitioners, using a variety of techniques on a range of mammals (dogs, horses… all get cataracts).  The key is to see it done in multiple ways in order to get a feeling for the varied and acceptable techniques.  This is great for building confidence.

  • Narrationthe learner must hear a narration of the steps of the skill along with a second demonstration.

Once again – pop onto Google / Youtube or any of the great FOAMed resources.  There are plenty of narrated videos showing it stage by stage. However, the best narration occurs when your teacher performs it live with you watching.  Connecting the audio with the visual in the flesh seems to lay down the memory more effectively.

  • Verbalisationif the learner is able to narrate correctly the steps of the skill before demonstrating there is a greater likelihood that the learner will correctly perform the skill.

This step is important to do immediately prior to performing the skill.  Better than simple verbalisation is what Cliff Reid calls “cognitive simulation” – mentally rehearsing the steps in one’s head.  For this procedure I was holding imaginary scissors in my hand and rolling along an imaginary eyeball to rehearse the motor action involved.

  • Practicethe learner having seen the skill, heard a narration, and repeated the narration, now performs the skill.

Practice, practice and more practice.  I was lucky enough to be able to repeat the procedure six times in one day.  Importantly, I insisted that my teacher continue to observe my technique and provide feedback.  The old “see one, do one…” is a myth. Usually it is the little things – the tips that experts do automatically, and only recall when they watch a novice perform them.  One patient’s block was technically challenging and I was required to troubleshoot with my teacher.  This is probably one of the most crucial steps – learning what to do when the plan goes awry.

So after a day of being the novice I have developed a few insights.  In order to teach a procedure – we should be walking our student through the above stages in order to make the most of the opportunity and maximise the chances of the skill ‘sticking’.  Unfortunately,  in most places I have worked there is usually little deliberate practice or any of the steps above.  Certainly this is how I learned most of my skills – trial, error and quite bit of patient harm I imagine.

To teach a skill the ideal mentor should:

  • have mastery of the skill.
  • be able to perform the skill with confidence and clarity.
  • be able to articulate the subtleties of the technique
  • be able to deal with the complications and fix errors
  • have the patience to allow the learner to “faff”.  Faffing is how one develops the feel / touch required.
  • keep the patient calm and reassured.  Anxiety can be a real block to effective learning
  • be prepared to give practical, realistic feedback immediately after the task

So if you are a trainee – please be proactive when learning skills.  Simply waiting for somebody to teach you on an opportunistic basis is not ideal.  You need to have done steps 1, 2 and maybe 3 in your own time.  You need to be prepared to complete the steps when the opportunity arises on your shift.  Most importantly – become an active “cognitive simulator” – mentally rehearse your technique and steps to lay down the motor memory.

If you are a teacher of procedural skills – thank you!  I was very lucky to have a patient and confident mentor this week.  He allowed me to faff a little and feel safe.  Probably the thing that helped me the most during my supervised subtenon blocks was the kind voice beside me saying: ” great…  keep going… that’s it!” – simple words but they really help to build confidence.  Much more helpful than the silence we often observe in these tense moments.

Let me know if you have any pearls for teaching procedures.  What did your favourite teacher do that made the skills easy to learn?


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CRACKCast E037 – Trauma in Pregnancy

This episode of CRACKCast covers Rosen’s Chapter 37, Trauma in Pregnancy. It’s amazing how much a body can change throughout pregnancy, and these changes warrant careful consideration by emergency physicians when a pregnant woman is involved in trauma. Show Notes  With trauma in pregnancy we need to think about blunt vs. penetrating trauma. Many women do not know they are pregnant. The top three causes of blunt trauma during pregnancy are: MVC’s Interpersonal/interpartner …

The post CRACKCast E037 – Trauma in Pregnancy appeared first on CanadiEM and was written by Adam Thomas.

Source: http://canadiem.org/