October 2018

Authors: Charlotte Davies, Katherine Henderson, Andy Neill, Becky Maxwell, Carole Gavin, Matthew Cooke, Dave McCreary, Damian Rowlands, Esther Murray, Pro Mukherjee/ Codes: / Published: 01/10/2018


The content you’re about to read or listen to is at least two years old, which means evidence and guidelines may have changed since it was originally published. This content item won’t be edited but there will be a newer version published if warranted. Check the new publications and curriculum map for updates

This topic has been a random and eclectic selection of snippets, with a vaguely wellbeing slant. We look forward to continuing the conversation. If youre interested in wellness in EM, theres a plethora of resources for you to look at including You Got This Wellness from Twitter and the EMTA resources.

The tarzan principle is often used as a tip for career advancement but you could also use it to emphasis how important swinging from holiday to holiday is.

Mindfullness tip taste something strong like coffee or a tangerine and play close attention to what happens in your mouth, and then what feeling these tastes evoke. Really try to appreciate how the object tastes, and how it makes you feel. Breath it in deep without thinking of anything else but that object and the feeling it provokes.

Mindfullness tip – Take 15seconds today, to save 30minutes. I was inspired to do this after listening to a BMJ podcast – but it can surprisingly really help. I took 15seconds to report the broken printer, which then saved 30minute trying to print. I took 15seconds to change the name of the fascia iliaca block guidelines on our guidelines drive, to save time finding it. For more details, listen to the BMJ podcast

Mindfullness tip – today get in touch with someone who has made a positive impact on your life and thank them, in any form. William Arthur Ward said “Feeling gratitude and not expressing it is like wrapping a present and not giving it”.

Your gratitude might be expressed in the form of a greatix, favourable event report (ferf), positive event report (PER) or what ever positive reporting tool your trust uses. More details in the show notes!




Mindfulness tip – when talking about STRESS reducton, one of the popular models is the “SHELL” models, and we can use everything we’ve learnt in this podcast to reduce Stress. S for software – so I’m going to have a traumatic pneumo algorithm, listing the evidence for not putting drains in. H for hardware – I’ll hide the tubes. E for environment – I’ll work on that. L for live-ware – human relationships are solved by my regular coffee chats. L for liverware – teamworking solved by reading all my books!!!

Codes: CC16

Dr Katherine Henderson, Clinical Lead at GSTT, talks to us about how to love your liver. It’s worth everyone checking out the love your liver screening tool. The bottom line is – fatty liver disease is dangerous, and is going to be a huge burden on the NHS. We all need to alter our modifiable risk factors – stop alcohol, stop smoking, stop being overweight, and start exercising.

Codes: HAP30, HAP31

If you’re not sure what emergency contraception to prescribe, check out our great blog here:

The rest of the content covered is beautifully in the RCEM guideline found on the RCEM website:

This was recorded as part of the @RCEMevents day “Flourishing in adversity: bringing the science of positive psychology into medicine”. Matthew Cooke (@EDDocUK) has done lots for leadership in healthcare, including introducing the four hour target.


It all comes back to ABC – Attitudes, behaviours, cultures

Random coffee trials are useful to help get you to know people.

Recommended Reading

It’s worth finding your own Leadership book, but two Matthew enjoyed are:

If Disney ran the hospital

Harry Potter General Electric

Codes: HMP3


Dave McCreary, Andy Neill

Clinical Question:

– Do all traumatic pneumothoraces need a tube?


– Conservative management in traumatic pneumothoraces, an observational study



– Walker, 2018, Chest from Southmeade, in Bristol


– Classic ATLS suggests all PTX need a tube. Especially if ventilation needed given risk of tension. Lots of us think this is silly and have stopped doing it especially in the PTX only visible on CT.


– TARN data for their sick (ISS 26) major trauma patients

– basically a review of registry data and their methodology is a little light here


– 600 patients from 3700 in their data set were included (17% PTX rate)

– of these a 10% mortality and 30% were ventilated

– 50% of PTX were simply observed (most less than 10mm). 90% of these enver needed anything and it didn’t seem to matter whether they were ventilated or not

– they look at a cohort with both CXR and chest CT (about a 125) and half of PTX were “occult”

– 10% tube complication rate overall but a tiny empuema rate here (0.6%) vs the oft quoted 15% that I’ve heard


– most of us are not placing tubes in these spontaneously breathing tiny PTX patients. I think this study should give us confidence not to drain the ventilated ones either

Codes: HAP30, HAP31

If you’re not sure what emergency contraception to prescribe, check out our great blog here:

The rest of the content covered is beautifully in the RCEM guideline found on the RCEM website:

This was recorded as part of the flourishing in adversity: bringing the science of positive psychology into medicine course organised by @global_em. @RCEMPresident talks about how important sustainable careers in EM are. Much of this guidance is covered in the college’s sustainable and satisfying careers document which can be found here

Rachel Rowlands was interviewed by Nikki Abela at PEMFest 2018 in Birmingham.

Moral Injury is the name given to that which many of us feel. It is covered well in emj.bmj.com by Esther Murray. St Emlyns have also covered it

Codes: PMP3

Authors: Dave McCreary, Andy Neill

Clinical Question:

– What is the rate of ICH in anticoagulated patients with GCS 15 with head injury?


– BJH, 2018


– Minhas (also including friend of the podcast Kerstin Hogg)



– head trauma in anticoagualted patients is common. NICE recommends CT for all, as do most guidelines. Anecdotal experience is yield is very low, especially in the asymptomatic GCS 15 patients.


– very well done, methodical systematic review

– included prospective data only on 1st presentation ED patients with all types of anti coagulation

– all were GCS 15 at triage (this is key i think)


– 5 studies all with extra data supplied by authors on request

– Vast majority warfarin patients

– 4080 patients with 209 ICH making a 5.1% rate of ICH (about 10% of these ICH were diagnosed at follow up)

– However due to the heterogeneity of the studies they use a random effects model and find a 9% (5-13%) incidence.

– in a sensitivity analysis (that only included the best trials) it was 10.9%

– a random effects model is a way of controlling for heterogeneity and assuring that one study doesn’t give too much weight to the final average. I don’t know enough stats to know if this is an appropriate thing to do but i suspect it is.


– note that Sue Mason’s AHEAD study (https://bmjopen.bmj.com/content/7/1/e014324) contributed almost 3/4 of the patients here and in their cohort of GCS 15 patients the rate was 4%. If you boil down to the GCS 15 with no symptoms it was 2.7% in AHEAD

– I will continue to order CT on almost all of the anticoagulated patients with head injury. I still suspect in UK and Irish practice the incidence of ICH is more towards the 5% than the 10% mark and so I’m rarely waking up someone in the middle of the night for a CT on a GCS 15 patient

– The other thing not addressed here is what constitutes a head injury – we see patients with simple scalp lacs from bumping their head off a corner of a shelf on standing – i do not think these should be treated like head injuries!

Codes: HAP6, HAP8

This month we’re talking PE and most importantly the Out Patient management of it. With a guideline published by the BTS in July 2018.

The first thing you need to decide is who is low risk and therefore could be considered for OP care.

There are a number of offered decision tools as you would expect.

PESI score has been validated in a population of 15000+ patients with very low risk patients having a mortality of <1.6% and low risk < 3.6% and no VTE recurrence or significant bleeding in the follow up period.

We should now think about reducing the risk of bleeding further. They recommend looking at clinical features to identify patients who are higher risk of bleeding and using these as exclusions for OP care.

What about lab tests I hear you ask. We love a good test in EM.

BNP not useful to help prognosticate in these patients.

Cardiac troponin alone or in combination with PESI did not significantly improve the NPV or NLR for mortality at 30 days.

HSTNT so we know that these are insanely sensitive, detecting tiny amounts of myocardial ischaemia. A single prospective study showed that combining sPESI and HSTNT led to 0 complications in their cohort compared with 2 and 4 in sPESI and hstnt groups in isolation

CT guided RV size measurement. Meta-analysis suggests 30 day NPV for mortality was 95% for all cause and 99% for PE related mortality, in the absence of RV dilation.

Treatment options:

There’s a myriad of different options including LMWH and DOACs and this guideline suggests non-inferiority with DOAC vs Heparin.



Pro Mukherjee (@ProMukherjee) set up an innovative project introducing Leicester medical students to mindfullness. This embraces some of the techniques that many of us have been introduced to over twitter.

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