ACEM2011 Day 1

Day 1 Summary:
Overall impression of day 1 of ACEM2011: Not bad
Some interesting themes raised in the educational talks. But as usual with big issue topics, more questions were raised than answers provided.
The trauma forum clarified my understanding of Damage Control Resuscitation and it’s limitations, as well as providing a great insight into the use of interventional radiology in trauma patients.  The Cardiology forum was OK, and I learned a few things about AF that I didn’t know before (which was surprising).
Downsides:
Michelle Johnston, Cliff Reid and I seemed to be the only ones active on social networking. Amazingly there were no tweets from @acemonline.
Took me until 5pm to figure out how to get onto the free wifi!
Didn’t charge my laptop properly last night, so fell into the Crap-Mac-Battery-life hole… So will take a bit longer to transpose my notes from my iphone to the site tonight!

Here’s a summary of the talks I went to today, I hope you find it informative.

1) Ronald Harden:
Inventor of the OSCE, world reknowned expert in medical education spoke about the past & future of medical education
Summary of Ronalds talk:
Previously medical education focused on the process of education, and problem based learning. There is now a move to focus on the product: learning outcomes and expected competencies.  Technology is taking on a much bigger role in medical education (der…): mainstays are E-learning & Simulation.

One of the big barriers to all of this is that we are taught in “silos”.
   Undergraduate/Postgraduate
   Specialist
   Continuing professional development
…with minimal or no connection between these programs. And unfortunately despite them all having high standards and idealistic goals, they often have contradictory messages or elements that counter-act the benefit of the others.
In an ideal world these would have some element of being linked to provide a more streamlined & consistent experience for the learners.

Some really interesting themes were raised including:
Transnational global learning
This is already happening – professors in Europe are doing online tutes to students in Africa, Middle East & elsewhere simultaneously. This means a more consistent level of information is being distributed, worldwide.

Outsourcing
All other big businesses do this, why don’t educational institutions?!
Why don’t medical educational institutions in Australia?

Sharing of information
Between individuals and between institutions
You can share content, expertise, horror stories, job-descriptions…
Many ED’s have shared conferences between local departments

Catalysts for change in the medical education field include:
Educational: Move to Outcome based education (OBE), Spiral curriculum
Technological advances: e-learning & SIM
Political will: can give international dimensions/mobility
Financial: potential huge savings in a collaborative training program

Discussion Points
Risk in focusing too much on Outcome Based Education (OBE) is losing focus on the process…  But: Should think about what outcome you want when you design the process.  ie the processes is critical, but if they don’t achieve the desired end, there’s something lacking

Risk of an over-arching body controlling things is potential suppression of ingenuity & individual expression/creativity.

As doctors and teachers we need to know about the theories of education & learning, and we all need experience in teaching.  Recognition that “we’re doctors therefore we can teach” is wrong is essential to progressing our education.

Risk of too much e-learning & simulation risks not teaching junior docs the “art of medicine” & how to deal with real patients.  Mitigated by having high quality students (hence the focus on selection), & high quality teachers.

2) Susan Promes:
Susan has started Emergency Medicine training programs from scratch in the USA, and spoke about the trials and tribulations of desiging and running Emergency Medicine training programs.

Summary:
(This is the EDExam opinion at the start…)
Compared to US ED training programs, Aussie ED’s seem to want to be far more insular, exclusive and “sell themselves” to trainees based on the merits of training at their hospital/network, despite the obvious parochialism and fact that they are usually (even in tertiary centers) relatively small, have few (or no) qualified teachers, only provide 5 hrs of highly-variable quality training time per week and no “on the floor teaching”.  A big drawback in Australia is also a lack of funds…

(This is what Susan had to say about it…)
Some ways to overcome these problems & enhance the educational experience of trainees include:
   Sharing didactic content: between individuals & institutions
   Using easily accessible databases for sharing information
   Fostering local relationships between local ED’s that aren’t in the same administrative network.
      For example: “If you do x for me/my trainees, I’ll do y for you/your trainees”
      Eg: teaching, tutes, testing, knowledge sharing
It’s about building relationships & balancing sharing with competition

One big barrier to sharing within/between networks is hospital management being too risk averse
ie Hospitals blocking certain online resources
Potential Solutions to this include:
   Lobby, Lobby, Lobby the individual networks/management
   Provide them with evidence of benefit & what others elsewhere are doing
   Look outside local health networks for resources
   Look to private sector/governing bodies for support

A push is on to analyse training programs (especially in USA) to see that the outcome is providing value for money for the people who are paying for it
and they are benchmarking competency! 

Comment from audience: a variety of environments for learning is key, as different people learn differently. This strategy picks up weaknesses that can be addressed as you go along, rather than using one method, and finding that it hasn’t worked when you fail the exam.  Going to tutorials at different hospitals, being exposed to a wide range of teaching methods & styles will maximize your learning.

Ronald Harden raised the important point: With the amount of information in the cloud:  We should be teaching trainees how to ask the right questions & how to access this information efficiently.

Victoria Brazil
Medical Education in Australaisa – trends, tribes, and a view from the dark side

Victoria spoke about the striking changes in the numbers of medical schools and graduates over the last 20-30 years in Australia, and some of the strategies being developed to cope with the tsunami of interns that has already started swamping us.
Some interesting factoids came out, including:
In 1984: 9 med schools in Australia.  Now: 20+ in Australia, 2 in NZ.
Class sizes are much bigger than before.
The cost of doing a medical degree here is around $55-60,000 per annum for private uni (Bond) and full fee paying overseas students, making it a lucrative business for unis (and it subsidises the cost for locals…)
Post-graduate entry is now much more prevalent compared to past.

Some demographic stats:
ED physicians in Australia: 70% Male. Average Age 45yo
The proportion of the medical workforce in Australia that is of Aboriginal or Torres Strait Islander background is disturbingly low: 150 out of 75,000 doctors.

There is evidence to show that medical students who do 6-12 mths in one rural location perform better than those who train in tertiary centres. Reasons for this include:
They adopt an identity
They follow patients over time
They integrate into the team & take responsibility

Some benefits of the new courses include:
Broader experience
Earlier clinical exposure
More rural/remote/indigenous exposure

Medical education has many, many players
Colleges, uni’s, registration boards & more
There is a very obvious and slightly disturbing lack of integration of players

Number of graduates is going up exponentially from 2005-2015
The “tsunami” – QLD  has tripled its numbers
Implications:
Limited capacity of existing intern training placements
Emerg Med in particular (mandatory part of intern training)
Many capacity constraints – no more ED’s/ED physicians
Solution
More in existing places
Expanded settings: private hospitals, alternative rotations: Radiology, pathology
MoLIE program
Off the floor teacihng (20% of time)
Case based learning
Costs a lot, but what’s it worth down the track…?

In some QLD hospitals – 100% of JHO’s are IMG’s
So there is a market for “free” interns (as the government pays for them not the local hospitals)

Standards for interns
Australian Curriculum Framework for Junior Docs, Confederation of Postgrad Medical Education Councils

BUT: MJA Sept 2011
The standard “in training assessment” = “pointless”

Options:
Mini-CEX
Direct observation of intern, with assessment of performance & feedback

RBWCHS
Compalres Mini-CEX to standard method of intern assessment
No additional summative impact
Huuuge amount of effort – lots of non-clinical time, admin time
= 10 extra weeks of consultant time = about $1million pa!!
For no summative impact.

Trends in specialist education in Aus:
Curriculum review
Professional educators
Competency based progression
Workplace based assessment…

But “apprenticeship” model still predominates

What does “competency” mean? – wide variation
Most ED physicans prefer informal ‘workplace based assessment” as opposed to time based qualification or “certification” from courses

Time doesn’t equal volume doesn’t equal quality
Average trainee used to do 2000 hours in resusc, now average = 700 hours…
This may or may not lead to a reduction in outcome, (due to a plateau in the expertise curve).

Need to teach & assess effectively before moving away from “time based” qualification/training.

The dark side:
We go through training asking “what’s best for me” and thinking it’s about us: BUT: It’s not about us…
Need to train in a way that makes doctors who are:
Cost effective
What patients need
Using their full range of skills

People are asking:
What changes in meducation will produce the largest gains in health for individuals and populations?

Australia has one of the largest number of working doctors and projected graduates per head of population in the world!

Selection of trainees
Need a “skills guarantee” based on research
Flexible pathways to general registration
Helps if you have clear set of outcome goals
Early streaming for those that want to start early
With some generalist input along the way
More flexible specialist training
Individual and collective responsibility to use medical education to produce Dr’s the patients & community need

MD Degrees in Australia:
Driven by marketing
Mostly Full fee paying students…
In QLD may be Commonwealth supported
Uni of Melb is starting an MD program.
Will it be better/more valuable than an MBBS?
May “water down” value of existing MD degree…

Coming up after Andy has dinner: Summaries of the Trauma forum and Cardiology forums!

TRAUMA FORUM:
Richard Cracknell (Liverpool NSW ED director)
Spoke about Damage Control Resuscitation, with a nice summary of the pathophysiology of bleeding in trauma, and a run through the evidence for the various techniques.

Key Points:
What is damage control resus (DCR)?
   Permissive hypotension = don’t “blow the clot off”
   Haemostatic resus = stop coagulopathy
   Limited crystalloids = don’t overfill/dliute
   Damage control surgery: stop bleeding, remove contamination = clean up & switch off the tap

Studied initially in military patients = Mostly penetrating trauma
Richard asked then: “Is this doctrine for ED?” as we see such a wide variety of patients.

PERMISSIVE HYPOTENSION
Wide variety of studies including a few reviews (Cochrane 2003, BMJ 2009 & J.Trauma), animal & human, nearly all penetrating trauma, showed no benefit or some benefit.  J.Trauma March 2011 – prospective RCT, published results from 1st 90 patients (of expected 271): Low MAP group used less blood products, less fluids (not significant), less coagulopathy, less early death BUT no difference in death at 30 days.  Important point was VERY rapid transfer to theatre times (like 15-20mins – does your ED do this?!). A further study looked at blast injury in a pig model, permissive hypotension not compatible with survival.

HAEMOSTATIC RESUSC
Roswell Aug 2011 J.Trauma: (Effect of high product ratio massive transfusion on mortality in blunt and penetrating trauma patients).
Blunt trauma: no benefit
Penetrating: Some benefit
Other less methodologically sound studies have shown some benefit

Other Hameostatic Things Studied:
Tranexamic Acid:
CRASH-2 (methods controversial). Essentially it’s OK to give it, but it’s best given early.  Click here to read the study & the now well known reply, and make your own mind up.
MATTERS study 2011 (again, sub-optimal design/methodology): TXA lowers mortality (but increased benefit with massive transfusion)
Factor 7a:
No benefit

SO IN SUMMARY:
Best use of permissive hypotension is in penetrating trauma (Caution: blast injury = no good)
Limited crystalloids: Limited data, not studied directly may be part of “whole process”
Haemostatuc resus: Benefit in penetrating, no benefit in blunt
Tranexamic acid: benefit in penetrating if given early
Overall:
Best to replicate other features of studies: eg fast theatre times

Watch out for: PROMPT Study = Upcoming US study for blunt trauma

 

John Harvey: Paediatric Burn Management
John, a Paediatric Surgeon gave an at times confronting talk about paediatric burn management.  Until we saw some of his pictures I imagined someone speaking about Little Johnny who got a scald from a hot tap… But oh no, John & his team see the worst of the worst in burned children, and it was an excellent talk that went through the basics (which John truthfully claimed are handled “universally poorly” by non-tertiary ED’s), right through to the management of airway burns, fluid resuscitation, SIRS, escharotomies, skin grafting and other surgical techniques.

Some take-home pearls that we got:
Some burns referral centers now offer a 24-hour digital photo consult service & burn management advice to peripheral ED’s.
The onset of SIRS in paeds burn patients can be prevented or delayed by good resuscitation, debridement & enteral feeding, as well as cerium nitrate baths
Upper Airway burns/swelling occurs early, lower airway burns are often chemical (from particles dissolved in mucus) and occur later.

 

CARDIOLOGY FORUM:

Peter Kas gave a talk about syncope.
It was a good recap of many of the studies and decision rules used in syncope, some key learning points (things we didn’t know about syncope beforehand or we think should be re-iterated:

1) Orthostatic hypotension can be diagnosed either by:
Drop in BP 20mmHg on standing
OR
Recurrence of Symptoms (with no drop in BP)

2) Can TIA’s cause syncope? Possibly yes! If you knock out your posterior circulation, therefore the patient is likely to have posterior circulation signs eg Vertigo/Ataxia.

3) A high percentage of the patients we admit with syncope get discharged without a diagnosis after their workup!

4) Take a history, examine the patient (including PR as indicated), and GET AN ECG ON EVERYONE with syncope

 

Stephen Macdonald (WA): Risk Stratifying ACS
Stephen spoke about risk stratifying ACS, with results from a study he was involved in comparing the TIMI score to the NHF/CSANZ score, looking at 30 day cardiac events.  The idea was to see which one you should use when deciding to send people home from ED after their negative chest pain workup.

The short synopsis is:
TIMI risk score = validated
NHF/CSANZ score – more complicated, some subjective findings,

When compared for the “low risk” end of the spectrum a TIMI score of 1 has higher 30 day risk than intermediate risk NHF/CSANZ  (5% vs 1.5%), which has implications for sending people home from ED, are you willing to accept a 5% 30 day cardiac event risk?

In a nutshell, NHF/CSANZ Guideline is more sensitive and specific than TIMI for prediction of 30 day events BUT TIMI is easier to apply, more objective.

 

Prof Ben Freedman: AF

“In AF treat the patient not the ECG!”

Reversion: What works?
WAITING!! 2/3 revert < 24hrs
Flecainide: need structurally normal heart
Amiodarone: less effective, delayed action, safe with abnormal heart
Everything else is rubbish, so don’t use it!

Vernakalant – new drug (not yet approved), showing promise as a reversion agent, so keep your eyes peeled (and good luck with the pronounciation!)

Rate Control
Ever wondered why we hammer the rate down below 100 before sending patients home or to the ward?
The rationale for getting rate < 120-130 in AF is to prevent tachycardia induced cardiomyopathy. Anticoagulation:
Cardio-embolic clots are big, and cause BIG strokes. To treat or prevent big clots, you need big anticoagulants.
CHADS2 is OK, but at the end of the day Aspirin has only a mild effect on reducing non-disabling stroke, no difference on disabling stroke.

Anticoagulate for 3-4 weeks pre and 4 weeks post cardioversion
Can use: Warfarin, Clexane, Dagibatrin: all are OK

HAS-BLED score
Risk of bleeding on anticoagulants
Not very helpful
Need to make a value judgement for your individual patient

Warfarin reduces stroke risk 66%.  Well controlled INR carries low risk of complications.

Adding plavix = no benefit, more bleeding

Dabigatran
Lower stroke risk, Similar major bleed risk
Less if < 65yo
more if high dose dabigatran & > 75yo
Less intra-cranial haemorrhage than warfarin

Asymptomatic AF
CONCORD study
7% over 65 have AF
About 10% dont know it!

Great web resource: www.atrialfibrillation-au.org