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HospitalAdministration

2d524508e314d884a1c4f440f1be0cc8
3
194

The Importance Of Clinical Skills

In the USA the issue of indiscriminate use of expensive, sophisticated, and time consuming test in lieu of, rather than in addition to, the clinical exam is being much discussed. The cause of this problem is of course multifactorial. One of the factors is the decline of the teaching of clinical skills to our medical students and trainees. Such problems seem to have taken hold in developing countries as well. Two personal anecdotes will illustrate this. In the early nineties I worked for two years as a faculty member in the department of ob & gyn at the Aga Khan University Medical School in Karachi, Pakistan. One day, I received a call from the resident in the emergency room about a woman who had come in because of some abdominal pain and vaginal bleeding. While the resident told me these two symptoms her next sentence was: “… and the pelvic ultrasound showed…” I stopped her right in her tracks before she could tell me the result of the ultrasound scan. I told her: “First tell me more about this patient. Does she look ill? Is she bleeding heavily? Is she in a lot of pain and where is the pain? What are her blood pressure and pulse rate? How long has she been having these symptoms? When was her last menstrual period? What are your findings when you examined her ? What is the result of the pregnancy test?”. The resident could not answer most of these basic clinical questions and findings. She had proceeded straight to a test which might or might not have been necessary or even indicated and she was not using her clinical skills or judgment. In another example, the resident, also in Karachi, called me to the emergency room about a patient with a ruptured ectopic pregnancy. He told me that the patient was pale, and obviously bleeding inside her abdomen and on the verge of going into shock. The resident had accurately made the diagnosis, based on the patient’s history, examination, and a few basic laboratory tests. But when I ran down to see the patient, he was wheeling the patient into the radiology department for an ultrasound. "Why an ultrasound?" I asked. “You already have made the correct diagnosis and she needs an urgent operation not another diagnostic procedure that will take up precious time before we can stop the internal bleeding.” Instead of having the needless ultrasound, the patient was wheeled into the operating room. What I am trying to emphasize is that advances in technology are great but they need to be used judiciously and young medical students and trainees need to be taught to use their clinical skills first and then apply new technologies, if needed, to help them to come to the right diagnosis and treatment. And of course we, practicing physicians need to set the example. Or am I old fashioned and not with it? Medico legal and other issues may come to play here and I am fully aware of these. However the basic issue of clinical exam is still important. Those wanting to read more similar stories can download a free e book from Smashwords. The title is: "CROSSCULTURAL DOCTORING. ON AND OFF THE BEATEN PATH." You can access the e book here.  
DR William LeMaire
over 3 years ago
Sink tap 695x434
3
20

A Summary of the NICE Intravenous Fluid Guidelines December 2013

The key parts from the guidelines that all of us working in the Emergency Department need to be aware of. Download the NICE guidelines summary  
heftemcast.co.uk
over 3 years ago
Preview
1
60

Anti-Thrombotic Therapy During Coronary Revascularization - Now@NEJM

Mr. Santana is a 67 year old man who presented to the emergency room with chest pain and was found to have ST-elevation myocardial infarction. He was taken to the cardiac catheterization lab for emergent coronary reperfusion. Which anti-thrombotic therapy should the interventional cardiologist use? What factors determine this choice?  
blogs.nejm.org
over 2 years ago
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2
53

Paediatric Minor Emergencies

There is a dearth of written work relating specifically to the emergency care of the child. Why this should be the case is perhaps not as perplexing as it may initially appear: although children make up between 25% and 30% of the attendance of many emergency departments, constituting approximately 3.5 million attendances a year (Royal College of Paediatrics and Child Health (RCPCH) 1999, 2007), there has until recently been little specific provision made for them.Whilst not addressing all of the challenges it is hoped that this work will provide some of the necessary knowledge for emergency nurses and nurse practitioners, emergency care practitioners, medical care practitioners, physiotherapy practitioners, pre-hospital staff and medical staff working in emergency departments, minor injury units, walk-in centres, out of hours services and other emergency care settings, that will enable them to enhance the care of the child with minor injury or illness.  
books.google.co.uk
over 2 years ago
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0
19

High flow systems for apnoeic oxygenation |

Apnoeic oxygenation during laryngoscopy via nasal prongs has really taken off in the last couple of years in emergency department RSI, and is associated with decreased desaturation rates in out-of-hospital RSI.  
resus.me
over 2 years ago
E5d96c4f1ce0f36b5b30c5dcd48dc937
5
612

Hello World, I've been to London's Air Ambulance for a bit...

Hi. Or rather, #HelloMyNameIs Adam. I like trauma, emergency medicine, PHEC, #FOAMed, twitter and scuba diving (but only when there's sunshine involved afterwards). I also like teaching and education, and I'm one of the final year medical students here in Edinburgh. But for 2 months I wasn't. I was one of the London's Air Ambulance elective students down in Whitechapel at the Royal London Hospital. So as an opening gambit, and by some way of an introduction I thought you might want to hear about that. After all, they're much more interesting than I am, and I can't host you for your elective… I managed to swindle my way into a 2 month elective with LAA just before Christmas 2014 and in a word it was pretty great. For those of you thinking of doing it, just go, now, and apply. Then you can come back and read the rest of my ramblings. For the rest of you, here’s what happened. LAA electives are a bit different, unsurprisingly. To cover its 1800-odd missions a year, LAA runs both their trauma service in two flavours: a helicopter (G-EHMS, aka “Mike Sierra” or MEDIC 1) by day and a car (DA “Delta Alpha” 77 or MEDIC 1 NIGHT) by night, (because apparently, whilst sporting and enjoyable for the pilots, landing in metropolitan areas in the dark is too risky, especially with comparatively empty roads). Alongside the trauma service, there is also a Physician Response Unit (PRU) which responds locally to cardiac arrests to provide quality CPR (along with some advanced post-arrest care like cooling and delivery to a cath lab), but for the most part does jobs for the London Ambulance Service which have been deemed probably not to require hospital, but might benefit from a doctor. There’s a 5 year waiting list for day-time flying shifts, and not much less for the rest of their work, so you’re not going to spend 4, 6 or 8 weeks in a helicopter flying round London taking names and saving lives, in fact the helicopter schedule is totally off-limits to students. Instead you’ll start off scheduled for a couple of night shifts each month and there will be opportunities to see a lot of London Ambulance Service, from the “control” at the Emergency Operations Centre (EOC), to time spent with road crews, and, off the back of some of the folk you’ll meet, a route in to observing with some more specialist units too. (More on that in the future if I run out of other ideas!) As well as the “live” experience there are 5 very experienced senior registrars from a variety of backgrounds as well as the 4 full-time LAA consultants, and opportunities to learn both practical skills and theoretical knowledge from them abound. As it turned out, the PRU was probably my favourite part of the elective. You can read about all the trauma that LAA goes to elsewhere, its splashed all over their shiny new website for a start, and many things have been written about their work (I might even write some more later on!) and there’s even a (not great) telly program on Channel 5. But the PRU is just really cool. I hate that word but it is. It fits into a strange, but now expanding niche in emergency care. That is, it serves to lighten the load both on the ambulance service and on the Emergency Departments of London by going out to people who have called 999 and asked for an ambulance but might in fact be better managed in the community. The work is incredibly varied, you can see older folk with a nasty UTI who couldn’t get to see their GP, you can go to a school and glue the head of a kid who’s taken a nasty fall in the playground, or you can end up in some sheltered housing talking to a lady who’s having the roughest of times and trying to deal with borderline personality disorder to boot. The PRU is crewed about half the time by a small group of GPs and EM docs who have been doing it for a while, usually about once a week or so, and quite often in their own time (in between the rota is made up with the LAA docs who usually work the trauma service). They’re kept firmly in line by an experienced LAS paramedic who is seconded over to run this unit, 9-5, 5 days a week, usually for about a year. As a team, they have perfected their ability to assess a patient using the minimal resources available to them, and as we are so often reminded, quite rightly, it turns out to be all in the history. Some interventions are available to them that aren’t available to paramedics, prescribing antibiotics or other drugs to leave with the patient, bypassing the ED for referral straight to specialists, and doing urine dipsticks being the most used among them; but mostly it is the team’s experience and advanced clinical judgement which makes this unit tick, and empowers them to safely leave so many of their patients at home, with care delivered, advice given, and a plan arranged should anything deteriorate. This wasn’t my first rodeo, I’ve been lucky enough to spend some time with the Scottish Ambulance Service up here in Edinburgh, and have spent more than my fair share of time in our Emergency Department, but it was still impressive to see how these guys dealt with the delicate balance of who to leave at home and who might need a further investigation in hospital. Firstly, this is something that anyone who aspires to work in an emergency department should aspire to be comfortable to do. There are going to be a huge number of people who don’t need to be admitted coming through it every day, wherever it is. The faster and more confidently you can identify their problems, treat them, and crucially, reassure them with appropriate advice, good follow up and a safety net, the better experience they will have. Of course much of this comes with experience and training, but tagging along with teams like this is a fine way to start getting some. Secondly, and this is a bit of a stab in the dark, but I think this idea really might take off. The media is almost swamped with stories of A&E departments being overwhelmed, ambulance services are operating at or near capacity, and we’re struggling to work out how we get the public to access the right care provider for their problem at that time. So maybe this is a solution. Maybe doctors, have a new role to play in assessing people earlier rather than people going through so many steps down a potentially unsuitable line of care. We’re starting to see consultants running triage at A&Es, we’re starting to see doctors out in cars like this. Get in on the ground floor guys and girls, I think we’re going to start being “first on scene” a little more often than we might be used to, even if you never leave the hospital.  
Adam Collins
almost 4 years ago
Www.bmj
1
21

An adolescent athlete with groin pain

A 14 year old boy felt a mild aching discomfort in his left groin while playing rugby but still continued to play. He subsequently tackled an opponent and developed a severe pain of sudden onset in the left upper thigh and groin. A “snapping” sound was heard and he fell to the ground. He was unable to bear weight on the left leg and appeared pale, clammy, and nauseated. His pitch-side vital observations were normal and he was offered combined gaseous nitrous oxide and oxygen for pain relief. Ice was applied to the area of maximum discomfort and he was accompanied to the emergency department in an ambulance. At the emergency department he was advised that he had probably “strained” a muscle and was given conservative advice. He was discharged with crutches and analgesia.  
bmj.com
over 3 years ago
92e75aa95f2fe324f53d875466ded4a8?s=200&ts=1457707111
0
11

A prospective observational study of ketamine for sedation of acutely agitated emergency department patients

#SAEM15 poster of ketamine for sedation of agitated ED patients. faster with similar side effects. @ketaminh @emcrit pic.twitter.com/30ySp4Wewt— jeff riddell (@Jeff__Riddell) May 20, 2015 @ketaminh @Jeff__Riddell @ToxTalks Working on stats for the paper as we speak! And the results point very favorably towards ketamine— Patil Armenian (@toxymethoxy) May 20, 2015 @ketaminh @Jeff__Riddell @ToxTalks Thanks! In…  
prehospitalmed.com
over 2 years ago
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1
6

Scottish emergency unit waiting times are lengthening

The number of patients waiting longer than four hours to be treated in hospital emergency departments in Scotland has almost trebled in recent years.  
bmj.com
over 3 years ago
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1
4

Pressure on emergency departments is having serious knock-on effect on hospital doctors’ work, conference hears

Physicians must have a central role in solving the current crisis facing the NHS, Jane Dacre, president of the Royal College of Physicians, told the college’s annual conference in Harrogate on Thursday 12 March.  
bmj.com
almost 3 years ago
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1
12

Public satisfaction with hospital emergency departments drops in Britain

Public satisfaction with hospital emergency departments is at its lowest level since 2008, the latest British Social Attitudes survey has shown.1 However, satisfaction with how the NHS is run was unchanged at 60%. Before 2004 the public’s overall satisfaction with the NHS fluctuated between 34% and 46%, and it then rose steadily to an all time high of 70% in 2010, reflecting higher NHS funding and shorter waiting times. But in 2011 satisfaction dropped sharply to …  
www.bmj.com
over 3 years ago
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0
10

GlideScope video laryngoscopy versus direct laryngoscopy in the emergency department: a propensity score-matched analysis

BMJ Open access article for your edification right here! GlideScope video laryngoscopy versus direct laryngoscopy in the emergency department: a propensity score-matched analysis Take home : Its a retrospective registry study so inherent biases therefore conclusions are not as strong. However it refutes some of the recent similar studies from USA, suggesting improved outcomes with…  
prehospitalmed.com
over 2 years ago
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1
11

EAHP 2014: Re-engineering clinical pharmacy services

Stream EAHP 2014: Re-engineering clinical pharmacy services by BMJ talk medicine from desktop or your mobile device  
SoundCloud
about 3 years ago
Www.bmj
1
15

An abnormality at the hepatic flexure

A 92 year old woman presented to the emergency department after collapsing at home. She recalled standing from her chair, feeling lightheaded, and then collapsing. She had felt generally weak for more than a year, with weight loss of 56 lb (25.2 kg) but no change in bowel habit, dysphagia, or gastrointestinal bleeding. Her medical history included hypertension, hypothyroidism, and anaemia (which was currently being investigated by her general practitioner). Among other drugs, she was taking lisinopril, bendroflumethiazide, and levothyroxine. Her son had died at 60 years of age from large bowel obstruction and perforation secondary to colon cancer.  
bmj.com
almost 3 years ago
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Teams under pressure in the emergency department: an interview study

Emerg Med J. 2012 Dec;29(12):e2. doi: 10.1136/emermed-2011-200084. Epub 2011 Dec 20. Research Support, Non-U.S. Gov't  
ncbi.nlm.nih.gov
over 3 years ago
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1
14

EAHP 2014: Re-engineering clinical pharmacy services

Stream EAHP 2014: Re-engineering clinical pharmacy services by BMJ talk medicine from desktop or your mobile device  
SoundCloud
about 3 years ago
Www.bmj
1
13

An adolescent athlete with groin pain

A 14 year old boy felt a mild aching discomfort in his left groin while playing rugby but still continued to play. He subsequently tackled an opponent and developed a severe pain of sudden onset in the left upper thigh and groin. A “snapping” sound was heard and he fell to the ground. He was unable to bear weight on the left leg and appeared pale, clammy, and nauseated. His pitch-side vital observations were normal and he was offered combined gaseous nitrous oxide and oxygen for pain relief. Ice was applied to the area of maximum discomfort and he was accompanied to the emergency department in an ambulance. At the emergency department he was advised that he had probably “strained” a muscle and was given conservative advice. He was discharged with crutches and analgesia.  
bmj.com
over 3 years ago
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0
12

Severe Hyponatremia in the Emergency Department

Hmm… he’s tasty, but he just needs a little salt. In this podcast, I discuss the management of hyponatremia in the ED.  
emcrit.org
over 2 years ago
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0
1

Management of calcium channel blocker overdose in the emergency department

A brief review of the management of the critically ill patient with a calcium channel blocker overdose in the emergency department  
first10em.com
over 2 years ago
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0
14

5 Scheduling Software Options in the Emergency Department: An In-Depth Review

5 Scheduling Software Options in the Emergency Department: An In-Depth Review. Covering Google Docs, MedRez, Amion, Shift Admin, and When To Work.  
aliem.com
over 2 years ago