Authors: Swagat Mishra, Gowthami Veera / Editor: Charlotte Davies / Codes: CC7, ELC8, ELP5, PhC1, PhP2, SLO10, SLO12, SLO2, SLO6, SLO9 / Published: 22/11/2022

The RCEM annual scientific conference this year was a hybrid one, which brought back the opportunity of face to face networking and interaction while catching it virtually at the same time. The app interface made it easy to access the event framework and contents, and ask questions in the chats in real time, which were systematically addressed at the end of every session. Only the lectures in conference hall 1 were streamed virtually so we could not cover the other sessions running in parallel. Attending it live had the advantage of going through the posters during coffee breaks, which covered such a wide range of topics. We’ve contacted a few poster authors and added their posters to the relevant blogs.

DAY 1

1.President’s address – Dr Katherine Henderson

Dr Katherine Henderson talked about her challenges with Covid and presidency. Some of the challenges were spotting the sickest, oxygen demands, PPE crisis, risks posed by undifferentiated patients to others, exhausted staff, how emergency medicine problems are not a political priority. In spite of all the challenges, she reminded us you need to maintain a sense of self worth, enjoy practicing medicine, balance bravery with risk to get the message across, and work as a team to get through this.

2. Saving EM: Is less more? – Professor Paul Atkinson

Dr Atkinson in his talk compared Emergency Medicine to the life boat of Healthcare. Someone dying because of a failing healthcare system is equivalent to killing by letting the system fail. Dr Atkinson’s paper – Saving Emergency Medicine: is less more? talks about the problems of the Emergency Department. We must pause and rethink “emergency” and clarify our primary mission. We need to establish accountability frameworks. As per Haddon, every patient who presents to the Emergency Department is a failure of the public health system. The problem is complex, but as a start three simple takeaways which Dr Atkinson emphasized were Resources, Training, Compassion.

 

3. Emerging evidence in our specialty: Lessons from backstage – Dr Caroline Leech

Dr Leech talked about research and how it changes practice. She tried to inspire emergency physicians to get into research. She briefly talked about her experience with the CRASH3 trial and the challenges around it like lack of research nurses, need for everyone to do a GCP training. She emphasized that if you want to do something, just start and you will learn along the course and gave supporting examples in the context of research. She then spoke on RePHILL trial, which concluded that blood products are not superior to crystalloids prehospitally when given to patients with traumatic bleeding.

Editor’s Note: It is also worth looking at the EM TERN resources.

4. Recreational drugs and novel psychoactive substances: What do I need to know about them? – Dr David Wood

Novel psychoactive substances are becoming less common in presentation in emergency departments. The three classes of drugs which form the majority of presentations are stimulants, depressants and hallucinogenics. He talked about some specific presentations. The first one is nitrous oxide which causes functional Vit B12 deficiency and leads to demyelination predominantly within the spinal cord. Blood tests include VitB 12 level, homocysteine, MMA and imaging is needed only if there is diagnostic uncertainty. Treatment involves IM Vit B12 injection and oral folic acid. Prognosis is usually good.

Next comes MDMA or tablets of “E” which can present with serotonin syndrome and significant hyperpyrexia. It’s important to rapidly bring down the temperature, check CK and evidence of AKI. For persistent hyperthermia, cyproheptadine or dantrolene can be used. Fentanyl should be avoided during intubation as it can cause serotonin toxicity.

Next is the “G”or GHB toxicity in which the patients usually present very flat but with protected airway reflexes and they wake up fairly rapidly. People usually don’t develop tolerance with GHB and can have an overdose and are also at risk of withdrawal if they stop it suddenly.

Next is synthetic cannabinoids which can cause neurological and respiratory depression and AKI. The AKI was initially thought due to vomiting and dehydration, but is now believed to be due to a direct nephrotoxic effect. Like cocaine has a increased risk of myocardial infarction, similarly cannabis too increases this risk and risk of arrythmia.

Editor’s Note: Have a look at our July 2021 podcast on B12,  MDMA or ecstacy blog for more of a refresher. 

5. When the doctor supplies the poison – Dr Philip Toner

Dr Toner started with paracetamol overdose and highlighted that it remains the leading cause of acute liver failure in the western world. He then talked about the SNAP protocol which is a 12 hour NAC regime which gives the same level of clinical outcome while reducing the adverse reactions and stay in emergency department. 

Another trial related to paracetamol is the POP trial which aims to assess safety and tolerability of calmangafodipir (PP100-01). He then talked about polypharmacy and deprescribing. Around 6.5% of UK hospital admissions are due to ADRs and it can lead to AKI, falls/hypotension and electrolyte disturbance.

Editor’s Note: Although they were written a long time ago, we have two podcasts on paracetamol poisoning that are well worth listening too. There’s also some paracetamol SAQs. All available on RCEMLearning here. Oh, and SNAP was covered in our VSC blog here. 

6. ABD: A terrible presentation – Dr Chris Humphries

ABD in the UK setting appeared in literature in 2013 and lots of organisations including RCEM have produced guidelines on this topic but there is still no consensus definition and that has led to some direct conflicts. He highlighted some of the problems which were faced during the production of the guidelines due to lack of evidence and clear consensus on definition. The points which he emphasized are that we need to improve future communication between different organisation’s work on the consistency of care and make clear terminology and reach a consensus.

Editor’s Notes: We’re the blog team so we’re biased, but we think our RCEMLearning ABD blog is one of the most interesting RCEMLearning ABD resources – have a read here. Of course if you want to listen to our podcasts on it, or access learning and reference sections we have those too – have a look here. 

7. RCEM free papers 5 x 15 minutes

a. The application of an age adjusted D-dimer threshold to rule out suspected venous thromboembolism (VTE) in an emergency department setting: A retrospective diagnostic cohort study, Dr Liam Barrett.

The application of an AADD appears to safely increase the proportion of patients in which VTE can be excluded without the need for reference standard imaging.

b. The composite outcome fallacy in the PRIEST Covid-19 clinical prediction score, Dr Kieran Dash

c. Integrating established clinical scores with a novel transcriptomic severity classifier augments early risk assessment in the ED, Dr Eva Diehl-Wiesenecker

NEWS2 score is used to triage patients and assess priority but even though they are sensitive, they are not very specific. (Forgotten what the definitions mean? Visit our resources here or here). Adding a novel transcriptomic severity classifier which uses quantification of 29mRNA via blood tests, can help better risk assessment of patients with infection, early identification and treatment.

d. In patients with chest pain suspicious for ACS, is arrival by emergency ambulance associated with increased likelihood of myocardial infarction? Dr James Murray

A secondary analysis of two cohorts from previous studies was done which showed that arrival by ambulance was linked with increased likelihood of having myocardial infarction but it needs to be replicated in other cohorts. There is also a possibility that those arriving with ambulance may have more comorbities which could be linked to increased risk of MI, which needs to be looked into.

e. Beyond the default male: exploring sex differences in the acute physiological response to trauma and associated clinical outcome, Dr Jennifer Ross

Dr Ross and team performed a study where they reviewed the data from Royal London MTC, and included patients with blunt trauma under 50 which showed that with similar injury and treatment, the outcome in women was worse than in me. This could be because of the physiological differences in men and women and the study needs replication in other centres.

8.Evolving the standard of care for acute infection and sepsis in the ED with advanced immune response diagnostics. Dr Tim Sweeney

An unwell patient with SIRS criteria can have a bacterial or viral infection or may not have any infection at all, and maybe some other inflammatory process. But most of them end up getting antibiotics which may not be the treatment they need. Blood cultures maybe negative in many bacterial infections and there is no single biomarker which can help with this decision. Dr Tim in his talk explained how gene expression changes in different inflammatory conditions and genomics can be used to predict where the inflammation is bacterial, viral or non infective, thus rationalising the use of antibiotics.

9. Clinical risk prediction: What are we predicting and why? Professor Steve Goodacre

Clinical prediction tools are used by physicians everyday for diagnostic, prognostic and therapeutic predictions. Prognostically we are using these tools to stratify patients in two categories of high and low risk and decide whether to intervene and act urgently or to discharge and refer back. Clinical decision tools should not be used to dictate decision making as they are better at predicting adverse outcomes but not necessarily predict that intervention will improve that outcome. Decision scores should be broken down to useful bits, and it should be considered whether adverse outcome is related to acute illness or underlying frailty and long term conditions.

10. Evaluating the EMLeaders Programme: Has it made an impact? – Professor Rosie Kneafsey

Professor Kneafsey explained the EMLeaders Programme and how the program has led to positive impact on doctor’s confidence in knowledge and application of leadership skills resulting in feeling empowered to make decisions and influence the EM workplace. It also led to many behavioural changes which improved teamwork, communication and self care and improved intention to remain in EM.

 11. COSTED (Cessation of Smoking Trial in the Emergency Department)

Dr Ian Pope talked about the COSTED Trial. While waiting in ED, people often start thinking about their health and that’s a good time to introduce an intervention regarding smoking cessation to the relevant population. Topics around quitting can be explored, advice can be given on switching to e-cigarette and referral to smoking services can be done. While recruiting in ED can be busy it has a lot of potential recruits.

 12. RCEM AGM

The AGM started with a welcome speech by the President and then report from the President on key college matters followed by a report from the Treasurer, then a report from Chief Executive, winners of various awards and then Presidential Handover.

 

DAY 2

1.President’s address – Dr Adrian Boyle

Dr Adrian Boyle, in his talk tried to explain how the RCEM has grown over time. He emphasised on the need for team growth and diversity. He acknowledged about the universal problem of wait times across all EDs in UK. He highlighted the difficulties faced in patient care in the ED. He also discussed about burn out of workforce of health care workers and gave suggestions on how to improve the working environment. He spoke about various allied sub specialities of emergency medicine and how emergency medicine has evolved over time. He spoke about RCEM priorities and about implementation of standardised healthcare and evidence based medicine and the challenges associated with the same.

2. Fabulous at 50: Reflections on UK Emergency Care – Professor Heather Jarman

Professor Heather Jarman in her talk walked us through the rise of emergency medicine in the UK right from 1972. Her talk was based upon the role of the emergency nurse practitioner. She emphasised the importance of need for trained emergency care nurses and their role in effective emergency care services. She highlighted the role of emergency nurse practitioner as equivalent or even superior to doctors in ED. She spoke about increased participation in career opportunities as an emergency nurse practitioner. She concluded by emphasising the role of the advanced clinical practitioner and barriers and stigma associated with research.

3. Improvement in the quality of care delivered to head injury (HI) patients presenting to the ED of a District General Hospital – Dr Mohammed Jamil Aslam

As we all know head injury has massive burden on the emergency department and greatest cause of death and disability under 40s, yet delays still cause harm. The criteria he aimed to improve against are:

  • High risk head injury patients are assessed by ED clinician within 15 mins
  • CT imaging performed with in 1 hr,
  • CTs reported within 1 hr of completion of scan
  • Final decision making was <4hrs

He talked about the problems that we are facing in DGHS in terms of delays in everything – triaging to transfer of images and getting referral response from tertiary care centre. As part of his quality improvement project, his implemented Interventions were head injury pathway, staff education, autovetting CT head scans (if fits head injury criteria) and an MDT approach to clinical decision making.

This head injury pathway alongside other interventions significantly increased the safety and quality of care head injured patients.

Highlights of the talk are

  • it is important to have clear defined process
  • optimise the utility of the workforce
  • continuous relationship building will bring about positive change with less resistance

4. The effect of the COVID-19 pandemic on major trauma presentations and patient outcomes in English hospitals – Dr Carl Marincowitz

Dr Carl Marincowitz talked about the study performed, using national registry data, on the impact on covid restrictions on the population characteristics, trauma care pathways and major trauma patient outcomes in England.

The methods were used in the study were

  • time series analysis of major trauma patients stratified by mechanism of injury
  • comparison patient characteristics and care pathways lockdown and equivalent pre-covid periods.
  • interrupted time series analysis to assess if risk adjusted survival affected by lockdown restrictions.

The conclusions of the study were:
mechanism of injuries: unexpected increase of cyclist related accidents and low falls (second lock down).
Demographics: uneven effect on older adults (second lock down).
ITS analysis: initial reduction risk adjusted survival, reassuringly improves outcome

5. Intubation success in prehospital emergency anaesthesia: a retrospective observational analysis of the Inter-Changeable Operator Model (ICOM) – Dr James Price

The speaker started off by pointing out the poor standards of trauma care in the UK, especially the ones with critical airway needs and exceeding the capabilities of statutory ambulance services, and then discussed the success rates of physician vs paramedics. Success rates were higher in the physician delivered intervention.

This was a representation of a retrospective analysis of Interchangeable Operator Model (ICOM) exhibits the advantage it has over NICOM, as it has significant benefits of an improved overall intubation rather than first pass success rate between both the physician and paramedics while treating trauma patients.

6. Why do emergency department clinicians miss acute aortic syndrome? A case series and descriptive analysis – Dr Rachel McLatchie

Dr Rachel talked about a case series cohort study which was a retrospective study with some limitations.

Aims of the study – To better understand why acute aortic syndrome is missed in the UK EDs and to characterise the presenting features of cases in which a diagnosis of acute aortic syndrome was missed.

Methods-case series cohort study. Setting was 3UK EDs, over 10yr period. Case identification, quantitative variables and reason for misdiagnosis determined by two independent reviewers per case.

Inclusion criteria –death from AAS at post mortem or diagnosis of AAS made on CT scan within 7 days of discharge from the ED whether discharged home or admitted under the speciality. A total of 43 cases were identified- the most common was Type A aortic dissection –approx 50%. The most common presenting complaint was chest pain –approx 63%. The most common false differentials were ACS and PE. The main reason for misdiagnosis was no evidence of consideration of AAS in differential diagnosis.

Limitations of the study –small sample size, retrospective analysis, dependent on documentation, irretrievable missing data, unable to draw conclusions about d-dimer.

Editor’s Note: Have a look at our RCEMLearning #RCEMAAD blog which collates all of our aorta resources. 

7. A multi-centre prospective observational study to evaluate healthcare impacts of e-scooters on EDs – Dr Tom Roberts

E-scooters have become a new mode of transport with claims of environmental benefits, in spite of the scepticism floating around, and have become an alternate commute for most people who used to walk or cycle their way to work. Albeit they have a downside of high speed injuries.

This was a retrospective study which started by quantifying the prevalence and nature of injuries, like, substance misuse (which is the highest incidence), helmets, private or rental scooters (mostly used) and the estimated costs they incur on the NHS.

The incidence of injuries can be tackled by comparing to other modes of transport, collaborating with transport experts and healthcare researchers and understanding the environmental impact.

8. Geospatial visualisation of ED attendance rates and their associations with deprivation and non-urgent attendances – Dr Joanna Sutton-Klein

In a general opinion, people who are deprived are more likely to have ill health and are more likely to attend ED. Deprivation is strongly associated with geographical location.

In this study, the UK is categorically and geographically divided and the data is collected from the smaller areas (LSOAs) in particular to analyse the overcrowding and deprivation at EDs and establishes that the population nearer to the ED are more likely to attend than the ones far away. And the EDs here are concentrated in the city.

The topic concludes with a looming question as to whether high deprivation and high attendance rates at the ED correlate with high population density.

9. Interventional cardiology beyond the stent – Dr Sarah Fairley

Dr Sarah Fairley, in her talk tried to explain the structured framework approach to ACS in New Zealand and problems with logistics, resources, accessibility to PCI facilities. Dr Sara emphasised on the demographic differences in cardiovascular diseases incidence and risk factors of communities that live in New Zealand compared to other parts of the world. Her talk also reflected socioeconomic disparities in different communities living in New Zealand and their difficulties in accessing health care services. She emphasised basic preventive cardiology in PCI inaccessible areas. Advanced Technology is irrelevant if basic healthcare to all is not accessible.

10. Funky devices, fancy tests and intelligent computers: ACS beyond 2022- Dr Rick Body

Dr Rick Body’s talk is based on Newer Tests & Devices and automation software in diagnosis of ACS. Since ED is high volume stressful environment with prolonged wait times, point of care tests are need of hour to rule out or rule in ACS in the simplest way possible.

High Sensitivity Troponin tests are calibrated to detect very low levels of troponin and hence have high sensitivity. Most of these tests are analysed on plasma samples hence not yet validated. Dr Rick also spoke about triaging tools like HE-MACS and HEAR which excluded troponin and highlighted their high sensitivity to rule in ACS.

Dr Rick also spoke about newer technologies like machine learning (T – MACS and MI3 ) and they are better than troponin and HEART Score alone. They allow for personalised medicine and decision support. Dr Rick even highlighted that smart watches like apple have inbuilt software to diagnose ACS and rhythm abnormalities in a non-hospital setting. Dr Rick emphasised the urgent need to disrupt clinical care pathways in order to make Point of Care Tests work.

11. Atypical cases of acute coronary syndrome: Case presentations Dr Andrew McNeice

Dr Andrew discussed various cases of aortic and spontaneous coronary artery dissection, coronary artery stenosis, stress cardiomyopathy that can present as atypical causes of ACS.

Dr Andrew stressed upon need for other supporting diagnostics tools such as ECHO, OCT, Intravascular USG, Cardiac CT/MRI in evaluation of patients with chest pain with no obvious risk factors of CAD/IHD and unlikely history. To summarise chest pain evaluation is clinical judgment with pre-test probability and one single diagnostic modality shouldn’t heavily influence decision making.

12. Controversies in chest injury Dr Edd Carlton

Professor Edd Carlton in lecture spoke about a change in practice in management of traumatic pneumothorax. He highlighted the change in trend from drainage of traumatic moderate non life threatening pneumothorax to observing managing conservatively. He also highlighted the clinical uncertainty, limited evidence, variations in practice with lack of robust guidelines while managing traumatic pneumothoraces.

13 RePHILL trial Dr Nicholas Crombie

Dr Nicholas Crombie summarised the evidence of blood products transfusions in trauma setting and evidence around trauma resuscitation and our current stance. He gave a brief summary of literature about trauma fluids resuscitation. He compared the resuscitation fluids available to use in pre-hospital settings and what impact the Rephill trial has had since its publication. He spoke about the introduction of on scene blood transfusions in a civilian physician led pre-hospital trauma which improved the ROSC rate from traumatic cardiac arrest secondary to hypovolaemia and increased survival to hospital but with no survival benefits. He emphasised the difference between packed red blood cells and whole blood transfusions. He quoted that none of the resuscitation trials till date showed a clear benefit of fractionated blood products over normal saline solution in trauma resuscitation. The upcoming Swift trial which has incorporated whole blood as resuscitation fluid is awaited.

14. Identifying models of care to improve outcomes for older people with emergency and urgent care needs Dr Simon Conroy

Dr Simon Conroy in his talk gave us insights about how to incorporate evidence based medicine in geriatric care to improve outcomes in elderly frail patients. He emphasised that there is reasonable evidence to support holistic integrated care with frailty competence in the ED leads to decreased admissions. He also stated that existing services loosely map to the evidence base and care handler designation is useful for risk stratification in addition to frailty. He walked us through elderly patients experiences and outcomes relating to emergency care. He emphasised the importance of incorporating the system’s dynamic modelling in emergency care pathways.

 

DAY 3

1.I get knocked down, but I get up again! 15 reflections on an EM research career – Dr Matt Reed

Dr Matt Reed, in his talk tried to explain how a career can be shaped around Academic Emergency Medicine. He mentioned about the development of Smartphone Palpitation Service and its inclusion in NICE guideline.

Some of the points he emphasized on were choosing a right research question, develop a research profile /portfolio, attend RCEM Research Training Day which happens in January every year, collaboration, learn how to say yes and take advantage of the opportunities, getting outputs and reflecting it on your CV, mentorship, making research part of usual care, learning from failures, innovation, embracing the data and time management.

For research inspiration, have a look at the TERN pages.

2. Emergency Medicine in the Pearl Of Africa – Dr Derek Harborne and Prisca Kizito

Development and quality improvement of emergency medicine in Uganda and setting up the infrastructure and standards, and the various challenges around it.

3. Re-Launching a research Portfolio -Dr Jason Smith

Dr Smith mentioned how Research needs funded time and the challenges posed by Covid in research;  domains and resources for research on TERN website;  how NIHR can provide help with research. There are several Research Priority Topics for Emergency Medicine and there are 72 topics on the RCEM website on research.

4. Rethinking Global Health: not a side issue but integral to EM – Dr Anisa Jafar

54% of the disease can be addressed by pre hospital emergency medicine. Attrition rates and factors responsible for this emphasise how we are losing staff and the impact it is having on healthcare. She explained how you do not necessarily have to move out of your geographical zone to practice global health. A good document highlighting some of these points is experts in our midst.

Global Emergency Care Collaborative is an online platform to get involved and collaborate for global healthcare.

5. An Editor’s Top tips for getting your research published – Professor Ellen Weber

She talked about why research papers rejected and encouraged us to ensure that papers include an important question, why this study is needed, what is the question, how your study is generalisable, and some mitigation for bias. The conclusion should reflect the findings and the study should not be overanalysed or under powered.

6. Fluids and Vasopressors in ED Sepsis – Dr Alasdair Corfield

He talked about the FEAST study which looked at the Mortality after Fluid bolus in African Children with Severe Infection. He talked about the REFRESH and CENSER studies which looked at the comparison of fluids vs early pressors, in which mortality benefit was shown in people started on early pressors. He talked about the anxiety around starting peripheral pressors, but clarified that a meta analysis looked at the complications, and it was just 3% and included itchiness, redness but nothing serious. So peripheral pressors are a lot safer than we think them to be. He also mentioned briefly the EVIS trial.

7. Novel rapid diagnostics for Infection and Sepsis – Professor Mervyn Singer

Dr Singer talked about the non infectious mimics of sepsis. Sepsis is not always very easy to detect and that’s why we need tools to identify it early and correctly. Blood cultures are not positive in a good subset of patients with sepsis but novel technologies like PCR can detect them. BIOFIRE is another such technology to rapidly identify sepsis. Different light based technologies are also coming for rapid detection of infections, and optical endomicroscopy can be used to visualise the bacteria in lungs.

8. Designing a Paediatric Study Prediction Tool using Machine Learning: AiSEPTRON Study, Dr Sylvestor Gomes

A majority of children presenting to ED with infective symptoms end up going home, but the challenge is identifying the ones who have sepsis. He pointed out that the current definitions of paediatric sepsis is not fit for purpose. He went ahead and talked about machine learning, and how it can learn from data and algorithms, and keeps getting better. He talked about the AiSEPTRON study which incorporates various parameters into machine learning to predict need for IV Antibiotics in children presenting in ED.

9. Panel discussion: Artificial intelligence – Prof David J Lowe, Dr Isabel Straw, Dr Alex Novac, Dr Shammi Ramlakhan

The panel talked about artificial intelligence and how it is going to modify medical practice. Artificial Intelligence, as the name suggests, is an intelligence which will help in making decisions. Data is fed into an algorithm, and as more and more data is fed, the algorithm improves itself. Data collection has become easier as most of the records are now fed into the computer. The artificial intelligence can help in controlling various medical devices, which a patient can regulate for his needs and can simply do with his phone. But at the same time, it presents the risks of being hacked or messed with and various new presentations which we might have to see in ED because of a malfunctioning or damaged device. 57% of patient attending ED get some kind of imaging done, and it forms a great pool of imaging data which can be used to develop imaging based AI, and it will increase the sensitivity of detection of positive findings by a less experienced observer.

We hope that’s been a useful glimpse into the world of the ASC. If you feel you missed out, make sure you book for next year!