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Authors: Liz Herrieven (day 1)/ Nikki Abela (day 2) Charlotte Davies (oral presentations) / Editors: The Blog Team / Codes: SLO9 / Published: 20/10/2020

Day One

I must admit, it felt a bit strange, taking a day off work as study leave to sit in my joggers in front of the laptop, but this is definitely The Way To Conference. I wondered if I’d miss the networking, but actually, as a bit of an introvert (off the shop floor, anyway), I definitely didn’t miss the hanging-awkwardly-around-the-coffee-table-waiting-to-notice-someone-I-know moments. 

Day one of the virtual scientific conference started with yoga. Honestly, I had every intention of joining in, but was otherwise engaged (recording a presentation for another upcoming conference, promise). It sounds like it went down well though. 

The conference itself was kicked off by a fab opening address from Katherine Henderson. She talked about the challenges our specialty has faced over the last year, but also the opportunities we’ve had, too. One of the points which struck a chord with me the most was about EM being a part of the solution for health inequalities rather than the problem, a safety net for the individual but not for the system. We’re used to being there for Always and Everyone (wasn’t that a TV programme??) but with increasing demand on the ED (particularly with the second COVID-19 wave AND winter upon us) we have to focus on what we do best – managing the acutely ill, injured or distressed. We are just part of a bigger system, which all needs to work properly, with proper funding and proper resources, for us to be able to do our job. 

Katherine also talked about the need for EM physicians to look after ourselves and our staff, as well as pointing out the College’s commitment to environmental sustainability. This holistic approach really felt appropriate for a specialty which is both broad and inclusive. 

RCEM relaunched the CARES campaign at the VSC, bringing a focus to crowding, access (we need to challenge the view that ED is the only point of access to the hospital), retention, experience (of both staff and patients) and safety. These things have always been important but deserve a special focus now, as we enter the second wave of the pandemic. Social distancing, busy waiting rooms and flow through and out of EDs was discussed, with acknowledgement that other specialties need to take care of their own patients and their urgent health needs. Some of the positives of COVID were mentioned too – including infection prevention and control. EDs have never been the best at this, so we’ve taken a huge step forward. For me, another positive has been the access to a huge and varied amount of online learning. We’ve had the opportunity to access many different webinars, conferences and learning platforms which I, at least, would not have had the time, money or availability to access In Real Life. There has also been the opportunity for our specialty to be recognised, particularly by those who may still think of us as Casualty, as our own, distinct specialty with our own role to play not just in the pandemic but in healthcare generally. (We have a separate blog on similar issues here).

After Katherine came Liz Crowe, talking about research into wellbeing. As always, Liz talked an awful lot of sense. She pointed out that most of the research in this area focuses on burnout, but, despite this, we don’t really know what scoring high on the burnout scale means. There’s a correlation with patient safety, for example, but no proven causation. Are we feeling burned out by the stress of knowing there are safety issues? Or are the safety issues a result of our burnout? Or neither? What is known is that burnout, or stress, or whatever else it may be called, is a strong emotional contagion. Liz pointed out that we, as ED leaders, have to “set the tone”, echoing two of my favourite doctors – Mark Greene and Andy Tagg. She talked about our capacity of resources as being like a bucket of water – what do you have in your bucket? What takes things out of your bucket? What puts things back in? 

Talk of boundaries resonated with me – apparently people with good boundaries do better when it comes to wellbeing, although Liz acknowledged that, for some, switching off from work completely can be anxiety-inducing itself. I’m terrible with this and know I need to do better, which I am, gradually (she says, whilst typing a blog at 21:07). 

Liz talked about happiness and I loved the fact that she gave us permission to not always feel happy. When wellbeing is talked about it often feels like there is a pressure to feel happy, or at least display happiness. She described how there are two forms of happiness (who knew??) – the hedonistic, in the moment, loving this ice-cream type, and the eudaimonic kind. I had to Google this, to make sure I got the spelling right and it turns out Wikipedia says other meanings for this include welfare and blessedness. That feels right, as Liz talked about the need for connections, or meaningful relationships, opportunities for growth and development, and a sense of meaning or purpose. I absolutely believe that these things can help to make you feel more content. In fact, they are the things that have kept me (and I suspect many others) going this year. Those meaningful connections I have with my work colleagues have made difficult shifts so much easier. Being able to continue to grow and develop during the pandemic, through learning opportunities in and out of work, and noticing different things about life have made lockdown less stressful and not only has COVID given EM physicians a sense of purpose but that purpose has also extended to our specialty, too. 

After an excellent start to the day, I had a choice to make. Room one or room two?? I stuck with room one, so I’m afraid this blog will, too, but I’m really looking forward to catching up with everything that went on in room two (FOMO). 

Professors Benger, Edwards and Mason talked about GPs in the ED. This was really interesting and an area that everyone has an opinion on. There’s huge variation across the country with regards to this – GPs in the ED itself or nearby, integrated into the department or working parallel. No single model suits every department. Either way, the aim is to place GPs where people go for primary care, rather than trying to change public behaviour. There’s some evidence that GPs can slightly reduce the number of re-attends within the week following initial ED presentation, but otherwise very little difference in patient experience or outcome. Patient perceptions and expectations play a role in the success, or otherwise, of this – if they perceive their problem to be an emergency are they happy to see a GP? Patients nowadays (don’t I sound old?) want to be able to access healthcare just like they can access everything else – 24/7, when it suits them best, in an accessible, familiar location. 

After lunch came the inspiring William Rutherford session, Under African Skies, led by Stevan Bruijns, Hendry Sawe and friends. I was too busy listening to take any notes, but this certainly put into perspective our concerns in the NHS. What the teams in low and middle income countries miss out on in terms of staffing and resources, they make every effort to make up for in terms of care, passion, innovation and improvisation. Maybe I need to stop complaining so much….? 

Toxicology came next in room one. The IONA study – analytical monitoring of the new drugs of misuse causing acute presentations to UK EDs – was presented by Simon Thomas. It’s pretty worrying how easily the recreational drug industry is able to produce new substances, usually mimicking established but illegal drugs, with slightly different chemical compositions in order to skirt around the law. The IONA team are attempting to help EM physicians keep up by looking for trends and linking symptoms with drugs. They’re still looking for more departments to join in, by the way. 

The SNAP protocol for n-acetylcysteine infusion came next, presented by James Dear. We don’t use this in my ED, so I was really interested to hear more. The idea is that the traditional 21 hour infusion doesn’t suit all patients who have taken a paracetamol overdose. Some don’t need it all that, some end up needing more, and side effects are a big issue. With SNAP, the Parvolex is given over 12 hours instead of 21, with liver function and paracetamol levels checked at 10 hours. This means that either the infusion can be stopped or, if more treatment is needed, it can be given earlier. There’s no difference in effectiveness and fewer side effects. Even better, and I would never have thought of this, is that a 12 hour infusion will usually finish in the day time, as most overdoses are taken in the evening or at night. Finishing in the day time, when mental health teams are around and more likely to be available to see patients, has got to be a winner, with a bonus of reduced overnight stays in hospital. 

The rest of the afternoon in room one was given to research carried out during the COVID-19 pandemic. The PRIEST study (triage tools, Professor Goodacre), the RECOVERY trial (treatments, Professor Haynes) and CONDOR (diagnostics, Professor Body) are all inspiring. We have so much to be proud of this year, and the way medics (particularly in EM) have mobilised not only to manage patients but also to find out as much as we can about this disease and how to manage it has to be right up there. It’s worth noting that throughout all these studies, the emphasis has been on allowing clinicians to look after patients first and foremost. There’s been a balance to hit between rapid and robust research, which I think has worked well. The RECOVERY trial in particular is fascinating. As a platform trial, it was ready to go before COVID reared its head, with the capacity for treatments to be added or removed from the protocol as results became apparent and new treatments came into focus. We also heard from Professor Dark, talking about adaptive trials in critical care, and Tom Roberts and Jo Daniels (TERN) who talked about the fabulous CERA study which looked at psychological distress in doctors during the pandemic. 

All round, a really interesting and inspiring day. I’m very much looking forward to day two, and to catching up on what I missed from day one. And yoga is back on tomorrow morning. I’ll be there. Honest!

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Day two

Do you have a patient lead in your trust? You probably should. If you listened to the David Williams lecture on #RCEMVsc today, the videos would have made you feel awkward.

“They put me in an empty room, on my own to wait for the mental health team. But because I was not assigned to anyone, no one really checked on me.” – That was the feedback from one of the teenage patients, who pointed out that the wait could sometimes be up to 12 hours.

We all know that this can happen in our trusts, and sometimes patients don’t say what we want to hear, but their view is so important. This was again echoed in the palliative care presentation for the Rod Little prize. I think if we had to reflect on our practise, this is something we really need to get right, for every patient, every time.

If you followed the same streams I did, you will notice there seemed to be a lot on traumatic brain injury. There is a fair bit of research going on in this area, so keep your fingers on the pulse and read the papers and abstracts. There was research on biomarkers to detect CT-undetectable TBI, concussion management, and the winner of the Rod Little Prize, using the mTBI Decision Rule for early discharge of patients with findings on CT, a Centre-TBI study. The CENTRE-TBI advances were then discussed in detail after the coffee break and I really urge you to head over to their website and have a look.

I swapped streams at that point, without the awkwardness of standing up and leaving the room, which was nice, and joined the panel talking about equality and diversity. There is so much we need to improve on with regards to equality and the micro-aggressions different groups of us face and unconscious biases we all have have a lot to do with it. It may be some time until we reach true equality, if ever at all, but we all need to shoulder the responsibility of striving for it, and acceptance of anything less is quite frankly, unacceptable.

I’m not going to apologise for only following the paeds stream after lunch as, “kids are cool,” as orthopaedic surgeon Daniel Perry pointed out. The context he was using is that their bones remodel really well (in the CRAFFT study he meant, but I think this is easily generalisable).  Damian Roland ran us through some notable paeds advances, including that IV magnesium reduces length of stay in asthmatics (Craig, Cochrane 2020), and that in children who present with head injury, giving ondanstron will not mask serious brain injury (Green-Hopkins, Ped Emergency Care 2020). 

If you’ve never been on a PEM Adventure with Dani Hall and Sarah Davies, it is worth going to a conference where there is one. And if the thought of a paeds transfer gives you the shivers, you need to prepare. Luckily we had interviewed Sarah Stibbards in 2018 so you can get a listen of how to do this here.

Unlike Liz, I missed the networking and social parts of the conference, even though this one was really well created and managed. I look forward to seeing all of you in person, hopefully in the near future. 

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Oral Abstracts

The oral abstracts session was phenomenal.

These oral abstracts were short powerpoint presentations with a video’d “head” of the presenter who was narrating the powerpoint. Some of the presenters were clearly less used to this method of sharing knowledge, and it was a great way to enable them to have greater confidence and comfort. Everyone that submitted an oral presentation has nailed the technology, and has passed their audition to join the RCEM Podcast team… why not get in touch! 

I consciously decided to filter out the COVID specific blogs, and luckily, despite this, it clearly got a mention and popped up. At King’s College Hospital they compared their safeguarding referrals during COVID to outside of COVID and found adolescent referrals to youth workers were higher.

Homelessness in the ED is a problem I’m not sure anywhere has solved yet – but the Homerton has made a fantastic start. 

I loved reading about the brilliance box, and have sent some anonymous cards, and contacted the designer. Learning from excellence is so important in EM – and I’ll have to add the brilliance box to my list of names and adjectives!

I’ve wanted to get e-leaflets and QR code videos into the department for a while and keep suggesting it as a QIP so I was delighted to see the work of Addenbrooke’s in doing just this.

https://twitter.com/murrellthemedic/status/1315941044735954944

It may be a conflict of interest, but as this poster on improved pain management in neck of femur fractures was created by my hospital, everyone should read it!

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That’s it from the blog team, it’s been a busy couple of days but we have enjoyed ourselves, synced at a distance, tuned into #RCEMVsc. Hope you have too. If you haven’t tuned in, you can still sign up to view it on catch-up. Well done to the organisers, it must have been a challenge to organise virtually, but it was pulled off in style. Until the next one. Over and out..

References

  1. rcem.delegateconnect.co delay diagnosis of brain tumour in children
  2. rcem.delegateconnect.co diagnosing spontaneous acute aortic dissection in the emergency department