RCEM conference places health and wellbeing of clinicians at heart of sessions

Day one: avoiding the wrong resuscitative mindset

After being welcomed to the conference by the RCEM President Dr Clifford Mann, we were treated to the keynote address by Dr Scot Weingart, a name that social media users may well have heard. Focusing on the human factors that are involved with emergency medicine decision-making, he spoke of key issues that will resonate with all ambulance staff, including a term known as ‘decision fatigue’. Here, he suggested that we only have a limited number of good decisions, and related this to some evidence of prison parole hearings whereby as the day progressed, people were less likely to receive parole. Interestingly, after a lunch break more parole was granted. It then began to wane as more decisions were made over an afternoon, highlighting the importance of food and a break, something many ambulance personal will understand. Weingart summed this up by stating: ‘When the hour's late, it admits their fate.’

Professor Stephen Goodacre spoke on the subject of pulmonary embolism (PE) in pregnancy. He highlighted the fact that PE in pregnant females has a low risk but has high consequences, indeed for many years it was the leading cause of maternal death, although that has now reduced. The key symptoms of chest pain and shortness of breath are typical findings in PE; however, these symptoms also feature in many women's normal pregnancies, making diagnosis difficult. Goodacre underlined some risk factors for PE in pregnancy including multiparity, increased body mass index (BMI), hyperemesis, gestational diabetes and recent hospital admission.

Following on from Professor Goodacre was Professor Timothy Coats, one of the key authors of the CRASH-2 trial. On the subject of tranexamic acid (TXA), it was explained that no pre-hospital studies of TXA had been conducted and that its use in this arena was a generalisation due to the evidence of greater benefit when given before 1 hour. Of interest was that the full action of TXA is still not fully understood and that its action may be more than an anti-fibrinolytic, possibly acting on inflammation as well. There are various trials ongoing with TXA around the world, which in the next 2 years may see this drug also being used for other conditions including gastrointestinal (GI) bleeds, which Coats explained uses more NHS blood products than any other condition.

Professor Fiona Lecky then spoke about traumatic brain injury (TBI), and highlighted a number of points worthy of consideration in pre-hospital care. She identified that there is no easy tool for the identification of TBI in the pre-hospital setting. Lecky further outlined that for patients with a TBI the average Glasgow Coma Scale (GCS) on initial presentation to the ED was 14, this is above the cut off for TBI triage tools. Concluding, it was presented that the highest percentage of those with TBI was the elderly faller, a point worthy of consideration for paramedic practice.

The subject of critical bleeding in trauma was next, a fantastic yet frustrating talk by the brilliant Dr Karim Brohi. The essence of the talk focused on the science of maintaining haemostatic competence. Brohi introduced the concept of two causes of coagulopathy: the disease (i.e trauma) and the clinician (in part referring to overzealous use of normal saline). He presented the fact that even in patients that received packed red blood cells, fresh frozen plasma, cryoprecipitate and platelets, when they were also given crystalloid they remained coagulopathic. He also highlighted the need to focus on marginal gains during pre-hospital treatment in order to achieve the best outcomes for our bleeding patients. For example, he recommended trying to preserve every drop of blood by early splinting, preventing hypothermia and doing the basics well.

To complement the session on the haemorrhaging patient, Dr Gareth Davies from London's Air Ambulance spoke about the advances of trauma care and possible developments in the future. Interestingly, he mentioned the prospect of ‘suspended animation’, whereby patients will be cooled to 10–14°C to near metabolic arrest; they will undergo the required surgical intervention and then be warmed. Aside from traumatic cardiac arrest, he briefly covered the subject of impact brain apnoea, a condition that all pre-hospital practitioners should be aware of.

The final session of note on the first day was a truly inspiring talk from Dr Cliff Reid. Reid spoke on the subject of being ‘cutting edge’ and offered some pearls of wisdom for ensuring that both the individual and the organisation are the very best they can be. In particular, he emphasised taking every opportunity to push yourself outside your comfort zone in preparation for those ‘bad jobs’, reflecting after every job and getting feedback on that patient you took to the ED. In respect of training, Reid mentioned the need to train in context and in the right environment; furthermore, training without any coaching or feedback does not promote learning.

Day two: how clinician interaction may influence a child's future

The second day continued in a similar vein to day one, with many interesting sessions. The morning began with some paediatric sessions. Dr Jeremy Tong spoke about the Paediatric Sepsis 6 to assist identification of sepsis. He also covered the emphasis on recognising the child with an inappropriate tachycardia despite receiving paracetamol, and the lack of crying in the visibly unwell child. These, he stated, had been consistent findings in those with sepsis. Another key point from the same paediatric stream was how we treat children: our interaction may influence a child's future, and as health professionals we have the ability to scare, enthuse, inspire or generate phobias. As such, a child's experience may shape how they react to future health care encounters. We need to remember this and always try to give children the best experience possible. Our manner and language need to be age appropriate.

Mr Rommie Duckworth, an American paramedic, gave a relevant and interesting talk on ED handovers. He highlighted the difficulty in both giving and receiving critical information in a short timeframe. With a great piece of audience participation he demonstrated how an individual's brain fills in gaps in information from the mental model that we start to generate from the small amount received, i.e. the pre-alert. This can be dangerous when the receiver starts to imagine things that may not have been said. This is not just the case for resuscitation room handovers, and Duckworth suggested that in the low-acuity, standard handovers the receiver is often conducting multiple concurrent tasks and is involved with high communication loads. This can lead to the risk of missing vital information.

The remainder of the day was spent sat in a number of sessions delivered by doctors from the defence service and technology laboratory. Topics covered the future of haemostatic resuscitation and ongoing research projects for the future of casualty care in the armed forces. These sessions were very compelling from a scientific background, and it will be interesting to see if findings from this research can be transferred to the civilian setting in the future.

Day three: considering the health and wellbeing of the clinician

Beginning day three was Professor Tony Redmond, who spoke on how the NHS responded to Ebola in West Africa. He explained how he was humbled by the sheer numbers of NHS professionals that applied to volunteer. Of the 1 643 that initially applied, 153 NHS workers were deployed, which required a great amount of support from the NHS. Undoubtedly this highlights the selflessness of those that work in the health service.

Following Professor Redmond was independent health policy analyst Mr Roy Lilley, who amazed with his slide-free talk. His awe-inspiring style and content engaged the audience and generated questions more than giving answers. By likening the NHS to a new kitchen, double glazing and his patio, Lilley questioned whether health care training reflected the job we actually do. This is something which historically many paramedics would agree with, especially in respect of conditions such as mental health and long-term complaints. Therefore, it is apparent we cannot change how we work if we do not change how we train. It is definitely recommended to see Roy Lilley speak if the opportunity arises, as you certainly will not be disappointed.

There were a number of sessions on the third day regarding wellbeing which were particularly thought-provoking. One speaker gave a sobering talk on coping after a medical error. The take home points were to speak openly and honestly with your trusted peers and colleagues if something occurs, but if you recognise a peer has had a difficult incident and they seem fine, still check up on them. If a particularly stressful shift has occurred then write down three positives from the shift. It is important for the individual to focus on positives and step away from any negatives. Another speaker touched on an interesting concept that an individual subjected to repeated tasks may see a decrease in compassion and an increase in fatigue, something we should all be guarding against in the current climate of long shifts and regular patient presentations. A further speaker suggested a ‘7 point plan’ to understand and practice in order to remain resilient and satisfied in your job, this included finding and emulating a role model, surrounding yourself with likeminded people and learning about your own emotions.

A third session on head injuries, this time by Professor Jonathan Benger, provided even more food for thought, challenging the usefulness of a single Glasgow Coma Scale (GCS) score, as well as our obsession with assessing pupil responses in the alert, orientated and conscious head-injured patient. A number of useful take home points were provided, such as the fact that when a patient is knocked out it generally takes around 90 seconds for the brain to ‘reset’, once this happens patients have a period of confusion and amnesia, similar to a postictal state. Benger commented that if the patient can remember being hit, it is unlikely they were truly knocked out; however, the theories for the action of being knocked out are still not truly understood. On the subject of assessing the head-injured patient, unilateral pupil dilation only occurs in significant head injury and is not seen in patients with a GCS of 15, 14 or even 13. By the time the optical nerve is affected by brain herniation other obvious clinical signs will be present.

Pick it, lick it, stick it was the message from a session on dental trauma covering avulsed teeth. For a fully intact tooth (root and crown) that has been knocked out, the chance of survival of that tooth decreases every minute. Therefore the best treatment is to replant the tooth within 5 minutes; however, if this is not possible then placing the tooth in milk will ensure the cells on the tooth remain healthy for up to 4 hours, no tooth should be replaced after 6 hours. Be aware for teeth in the airway or already inhaled, if found outside the body then handle only the crown (the part we see), clean by getting the patient to suck it and place it in to the hole, bite down gently on a piece of gauze for a couple of minutes. The exceptions for replanting are: baby teeth, immunosuppressed patients, a neglected and diseased mouth, and patients with head injuries or other time-critical emergencies.

Conclusions

The RCEM conference was hugely enjoyable and provided delegates with a great number of areas for further consideration. For readers wishing to find out more detailed information on the sessions, Twitter played an active role in the conference. Searching #RCEM15 will provide a vast amount of pictures and points from every session. While this review only gives a small insight into the content of the 3 days and the possible impact on paramedic practice, every session was interesting and thought provoking. What was particularly impressive was the large amount of sessions regarding the health and wellbeing of the clinician. We all want to do the best for our patients, but firstly we need to look after ourselves and our colleagues. As the conference came to a close, delegates left feeling positive, inspired and reassured that other members of the emergency medical family have shared experiences.