Author: Charlotte Kennedy / Editor: Govind OIiver / Codes: C3AP2a, CAP1, CAP23, CAP33, CC20, CC23, CC9, HAP1, HAP19, HAP26, HAP29 / Published: 07/02/2019
Research in Emergency Medicine ranges in scale and complexity and covers a wide spectrum of subjects, all of which contribute to our overall knowledge base. The Trainee Emergency Research Network (TERN) aims to highlight the diverse range of ways that people can become involved in research. In this month’s Breaking Evidence section, we present the work conducted by those that won prizes at the recent Emergency Medicine Trainees’ Association (EMTA) conference. We hope that these highlight the range and diversity of projects being conducted by trainees and inspires people to consider the different ways in which they can undertake academic activities within their own departments.
‘Food for thought: hyperacute abdominal pain after lunch’
By Dr L. Greenfield et al. from Royal London Hospital
This case report presents the history of a man attending the Emergency Department with severe acute abdominal pain of sudden onset after eating, associated with syncope. On examination he was found to have a diffusely tender abdomen with guarding on the right side. He was initially investigated with blood tests which showed a raised white cell count, normocytic anaemia and a high lactate. Chest x-ray were normal and he went on to have a CT scan. This revealed a large angiomyolipoma in the right kidney with associated retroperitoneal haemorrhage.
Angiomyolipomas (AMLs) are a type of neoplasm arising from the epithelioid cells around blood vessels. They are composed of varying amounts of fat, vascular and smooth muscle cells. Renal angiomyolipomas were previously thought to be rare; however, their identification is becoming more common with the increased use of imaging. A Japanese study that undertook ultrasound screening in healthy adults reported an incidence of 0.1 0.2% of the population, with a female to male ratio of 2:1 (1). Around 80% of cases are sporadic, with the other 20% being associated with neurocutaneous disorders, the most common of which is tuberous sclerosis (2). The tumours are typically benign and are usually asymptomatic, with over 80% of cases now identified incidentally(2). Symptomatic AMLs most commonly cause flank pain but may also cause gross haematuria, a palpable mass or renal failure. Retroperitoneal haemorrhage is rare, occurring in less than 15% of cases (2), but can be severe and lead to shock. It is more common in tumours over 4mm in size and the risk of rupture is proportional to the tumour size (3). Management depends on the size of the tumour and the presence or absence of symptoms. Acute haemorrhage should be managed with emergency embolization (4). For larger, multiple or symptomatic lesions there are a range of options such as surgical intervention, embolisation or radiofrequency ablation (4). Some smaller lesions may be monitored with close follow-up but we suggest in the first instance that most cases found in the Emergency Department will need discussion with urology.
‘The impact of Pre-hospital Emergency Medicine exposure on training experience for Emergency Medicine trainees’
By Dr L. Ramage et al. from Barts Health NHS Trust, London
The Royal London Hospital offers, as part of its Emergency Medicine (EM) higher specialist training, the chance to undertake clinical observer shits within pre-hospital care, shadowing the Physician Response Unit (PRU) which operates throughout North-East London. The authors of this poster conducted a retrospective questionnaire to obtain information on trainees perceptions of this element of their training. The questionnaire was sent to all trainees that had worked at the Royal London Hospital since 2008 and consisted of both qualitative and quantitative data collection elements, with the later being assessed using Likert scales.
In total, 28 responses were obtained. The number of shifts that each trainee had undertaken with the PRU varied, with 19 (68%) trainees undertaking up to 4 shifts and 4 (14%) trainees undertaking more than 12. In general, the responses were positive, with 89% of responders saying they enjoyed the experience and 93% stating that they felt that undertaking PRU shifts improved the overall training experience whilst working at the hospital. With regards to general training, 78% felt that the shifts supplemented regular EM training and 89% felt that pre-hospital training opportunities should be provided to all EM trainees. Themes that were raised from the qualitative work included the improved personal wellbeing of trainees secondary to alternative training experiences, an improved understanding of the trainees’ local community and reinforcement of the importance of taking a social history. Trainees also felt that the shifts enhanced their multi-disciplinary team working due to a better understanding of the skills and aptitude of the pre-hospital team. We hope to see more on this from the authors in the future as it sounds like a fantastic opportunity to enhance training and enable exposure to pre-hospital medicine for EM trainees.
‘Pain scoring in the Emergency Department’
By Elwyn Jones from Prince Charles Hospital, Merthyr Tydfil, Wales
This quality improvement project focused on pain in the Emergency Department (ED). The Royal College of Emergency Medicines (RCEM) Best Practise Guidelines summarise the suggested assessment and management of pain in patients presenting to the ED (5). They stress the importance of recognising and treating pain but acknowledge that assessment of pain in the ED is often suboptimal. They suggest that assessment should start at triage and recommend using a scale of 0 – 10 subdivided into mild (1 – 3), moderate (4 – 6) and severe (7 – 10) pain. For mild and moderate pain, they recommend that oral analgesia should be administered within 20 minutes of arrival and pain reassessed at 60 minutes. For severe pain they recommend either rectal non-steroidal anti-inflammatories (NSAIDs) or intravenous opiates, administered within 20 minutes and re-evaluated at 30 minutes.
The project itself looked at the impact of staff training on the assessment and documentation of patients pain scores at triage. During the initial evaluation cycle, the notes of patients waiting to be seen were examined prospectively once a day for 5 days and information collected on the number of pain scores completed and whether analgesia had been administered. Prior to the intervention, 15 out of 66 patients (23%) had a pain score recorded and 45% of patients were offered analgesia. After raising awareness of the importance of pain scores amongst staff and producing posters for the triage rooms, the number of patients with pain scores recorded increased to 30 out of 57 (53%) with 61% of patients being offered analgesia. Despite the improvement, still only around half of patients were having a pain score recorded at triage; this is something we would urge people to think about in their own departments, to consider whether patient’s are receiving optimal analgesia as early as possible when attending the ED.
‘The value of ultrasound in the diagnosis of partial tears of the Achilles tendon’
By R. Navaratnam from East Sussex Healthcare NHS Trust, East Sussex
The author conducted a systematic review on the efficacy of ultrasound in diagnosing partial tears of the Achilles tendon in adult patients. The use of ultrasound for the diagnosis of partial and total Achilles tendon rupture is controversial; the National Institute for Health and Care Excellence (NICE) states that Achilles tendinopathy is a clinical diagnosis and that those suspected of rupture should be referred to orthopedics (6)whilst the American Academy of Orthopaedic Surgeons has previously stated that there was inconclusive evidence to support the use of any particular imaging modality (7). Up to date recommend the use of ultrasound but acknowledge that the evidence behind its use is limited (8).
For the systematic review, the author searched Pubmed, Embase and Medline using keywords, with results limited to those published in English and from the year 2000 onwards. Additional papers were sought by searching the reference lists of included studies. In total, 203 papers were initially identified by the searches, with 32 being read in full and 4 meeting inclusion criteria. 2 of the studies compared ultrasound to intraoperative findings, whilst 2 compared ultrasound to magnetic resonance imaging (MRI), which is considered the gold standard (9).
All of the studies found were small, with participant numbers ranging from 18 to 88 (1013). In the paper by Kayser et al. (2005) comparing ultrasound to MRI, ultrasound detected 12 patients with Achilles tendon abnormalities, one of which was thought to be a partial rupture. However, on MRI examination, 3 of those thought to have tendinitis and one patient thought to have peritendinitis actually had a partial tear of their Achilles. In the study by Ibrahim et al. (2013) ultrasound correctly identified 11 out of 14 patients with partial tears on MRI and correctly identified all 4 patients with full thickness tears, giving a sensitivity and specificity of ultrasound for diagnosing Achilles pathology in general of 86.6% and 77.4% respectively. These results are similar to those comparing ultrasound findings to intraoperative examination. In the study by Sheikh et al. (2015) 47 patients with clinically suspicious and ultrasonographically confirmed tendon rupture underwent operative exploration. Ultrasound correctly identified 29 complete ruptures and 15 partial ruptures of the Achilles; 3 patients thought to have a partial rupture on ultrasound actually had a full rupture at the time of surgery. In a similar study by Margetic et al. (2007) ultrasound correctly identified 78 complete Achilles ruptures and 2 partial ruptures but 8 patients thought to have a partial tear were found to have complete rupture at the time of operative intervention. Overall the authors of the systematic review conclude that whilst ultrasound appears to be useful, it is not yet reliable enough for the diagnosis of partial tears. It is also important to acknowledge the limitation of the studies conducted so far, most of which are limited in their sample sizes and often lack explanation on who was conducting the ultrasound, a consideration which is likely to affect the results, particularly when trying to generalise the results to an Emergency Department setting.
‘Returning to the Emergency Department’
By Dr A. Hughes from the Yorkshire and Humber Deanery
The author described the process she went through to organise a course for those returning to work after a leave of absence. The Academy of Royal Colleges has produced guidance for doctors returning to practice that outline the responsibilities of the doctor and their employers (14). The guidelines suggest that any absence from work longer than 3 months is likely to significantly affect a doctors knowledge and skills and should prompt a return to practice review, although it acknowledges that even those taking less than 3 months off may have additional needs when returning and should be offered individualised support where necessary. It also suggests that those taking more than 2 years may need formal re-training. The document contains some useful checklists which can be used to plan a return to work and suggests possible ways to make the transition back to work easier, making it a potentially useful guideline for those returning to work after a leave of absence.
The one-day course organised by the author aimed to address some of these issues by improving returning trainees confidence in management, leadership, communication and clinical skills through simulation, demonstrations and workshops. Topics covered included adult, paediatric and neonatal life support; trauma management; safe sedation; minor injuries and clinical updates in Emergency Medicine. After gaining support for the course from her local head of school, a grant was applied for and awarded by Health Education England. The course received excellent feedback and has now been taken up by the deanery to be run on a bi-annual basis. We think it sounds like an excellent initiative and hope this inspires others to consider setting up similar schemes in their area.
‘The use of exit interviews to identify changes in Emergency Department junior experiences from 2016 to 2018′
By Dr E. Yinkore et al.from University Hospital Coventry and Warwickshire
The author described their Emergency Departments experience of conducting exit interviews with trainees rotating out of the department, in order to try and improve training over time. Exit interviews are used in many environments outside of the NHS to understand what the employee thought of the organisation and to explore the reasons for that person leaving; the premise being that employees who have left may be more likely to provide open and honest feedback. This can then be used to drive change. Exit interviews are rarely used in the NHS but may be a valuable tool for improving trainees experience of working in the Emergency Department. The authors conducted semi-structured interviews with 21 junior doctors in 2016 and 25 juniors in 2018, using the interim to try to improve on the feedback from the original interviews. The interviews lasted for 10 to 15 minutes and were conducted by peers in order to encourage honesty and break down potential hierarchical barriers. Results were analysed using thematic scheme analysis.
The positive aspects of working in the Emergency Department that were highlighted were similar over both years and will probably not surprise most of us working in the specialty. They included the variety of the job, working in resus, the ability to conduct procedural skills and the senior support that was offered in that department. Similarly, the negative aspects reported are ones that most of us are likely to encounter and be frustrated with too: the time pressure, rota problems, and working in areas we are less confident in such as paediatrics and minors. Interestingly, the negative feedback did change between the years for the Department due to changes they implemented, showing what a useful resource exit interviews could potentially be. With small changes to the department the number of trainees that reported feeling they had received enough training increased from 63% to 76% and the number of trainees that reported they were more likely to go into Emergency Medicine rose from 52% to 60%. Exit interviews may be a useful way to improve the training experience of junior doctors and we hope to see more people take initiatives like this in the future.
- Fujii Y, Ajima J, Oka K, Tosaka A, Takehara Y. Benign renal tumors detected among healthy adults by abdominal ultrasonography. Eur Urol. 1995;27(2):1247.
- Flum AS, Hamoui N, Said MA, Yang XJ, Casalino DD, McGuire BB, et al. Update on the Diagnosis and Management of Renal Angiomyolipoma. J Urol. 2016;195(4 Pt 1):83446.
- Knipe H, Amini B. Renal angiomyolipoma [Internet]. Radiopedia; [cited 2019 Jan 26].
- Torres V, Pei Y. Renal angiomyolipomas [Internet]. Up to Date, Wolters Kluwer; 2017 [cited 2019 Jan 26].
- The Royal College of Emergency Medicine. The College of Emergency Medicine Best Practise Guideline. Management of Pain in Adults [Internet]. The Royal College of Emergency Medicine; 2014 [cited 2019 Jan 26].
- National Institute for Health and Care Excellence. Achilles tendinopathy, NICE Clinical Knowledge Summaries [Internet]. 2016 [cited 2019 Jan 27].
- American Academy of Orthopaedic Surgeons. The Diagnosis and Treatment of Acute Achilles Tendon Rupture. Guideline and Evidence Report [Internet]. American Academy of Orthopaedic Surgeons; 2009 [cited 2019 Jan 27].
- Maughan K, Boggess B. Achilles tendinopathy and tendon rupture [Internet]. Up to Date. 2018 [cited 2019 Jan 27].
- Gulati V. Management of achilles tendon injury: A current concepts systematic review. World J Orthop. 2015;6(4):380.
- Kayser R, Mahlfeld K, Heyde CE. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Br J Sports Med. 2005 Nov;39(11):83842; discussion 838-842.
- Ibrahim NMA, Elsaeed HH. Lesions of the Achilles tendon: Evaluation with ultrasonography and magnetic resonance imaging. Egypt J Radiol Nucl Med. 2013 Sep;44(3):5817.
- Sheikh H, Azzam W. Can ultrasonography distinguish between complete and partial rupture of the Achilles tendon? A sonographic operative correlation. Tanta Med J. 2015;43(4):120.
- Margeti P, Mikli D, Raki-Ersek V, Doko Z, Lubina ZI, Brkljaci B. Comparison of ultrasonographic and intraoperative findings in Achilles tendon rupture. Coll Antropol. 2007 Mar;31(1):27984.
- Academy of Medical Royal Colleges. Return to Practice Guidelines [Internet]. Academy of Medical Royal Colleges; 2017 [cited 2019 Jan 27].