This 6 year old girl presented to a local MIU complaining of a sore forearm after falling off a climbing frame. It was difficult to elicit the site of maximal tenderness and the following X-ray was performed:
What does the X-ray show and how would you manage it?
I attended a recent study day, and one of the speakers was from the GMC. The GMC has numerous publications, and it can be challenging to keep up with all the guidance. We discussed 2 topics, one which I knew nothing about and thought I'd share.
Patients recording NHS staff in health and social care settings
Doctors' use of social media
This is an important guide to be aware of, as social media is increasingly becoming more and more part of our daily practice. The use of social media is not limited to Facebook! There are very few teams now that do not make use of a messaging app, and we should make sure we maintain patient confidentiality.
There are many new apps available marketing themselves as "NHS compliant", "GMC compliant" for communication use between clinical teams. They may well replace the bleep / referral system one day!
Have a look:
These may well be a better option than WhatsApp...
I started this morning innocently reading a recent blog post by the St Emlyn's Team with the intention of screening large numbers of recent blog posts as part of my weekly CPD update. Low and behold, it is 5pm and I am still stuck on this one post and topic: ATRIAL FIBRILLATION. I should have known reading something about AF would not be a simple task!
I am sure I am not the only person who feels a little overwhelmed from time to time when faced with decision making in the management of AF. I guess it is because it does not fit in a neat box of a single answer for every event.
I thought I would summarise a few key points I have reviewed today:
2. Aim of treatment
RATE CONTROL vs RHYTHM control
MEDICATIONS FOR RATE CONTROL
NICE: Offer a beta-blocker or a rate-limiting calcium-channel blocker (diltiazem [off-label use] or verapamil). The choice between a beta-blocker and a calcium-channel blocker will depend largely on the person's comorbidities.
IS TROPONIN NECESSARY FOR ALL ACUTE AF PATIENTS IN THE ED?
AF WITH WIDE QRS
A 78 year old man with history of Type 2 diabetes mellitus and hypertension presents to the emergency department with Right shoulder pain. The paramedics are concerned as they have found a Left bundle branch block on his ECG.
On arrival he appears to be in pain but he has a normal complexion and is not diaphoretic. His vital signs are:
HR 98, BP 145/80, RR 18, Sats 97% on air, temp 37.2
On further questioning his GP has been treating him conservatively for a pain in his right shoulder for the last month following its sudden development after “jolting” it whilst cleaning the car.
He has been otherwise well but the pain in his shoulder has been getting progressively worse and is now debilitating. It is worse with movement but he hasn’t noticed any change with exertion per se.
Examination reveals a clear chest, dual heart sounds with no murmurs and a soft non tender abdomen. Examination of the right shoulder reveals a fullness at the sterno-clavicular joint which is painful to palpation, this has been present since cleaning the car. There is no bony tenderness elsewhere. He has full range of movement of the shoulder but all range of motion is painful. His right limb is neuro-vascularly intact.
As part of the work up an ECG is undertaken which confirms a LBBB, serial troponin tests are negative and the Chest X-ray can be seen below:
With a keen eye you may notice the calcific deposit in a rotator cuff tendon above the greater tuberosity of the humerus concerning for calcific tendonitis, but did you notice anything abnormal about the clavicle?
On closer inspection the proximal half of the clavicle is missing.
A CT scan was conducted which demonstrated a soft tissue density mass overlying the medial aspect of the right clavicle which had been eroded with extension into the antero-superior mediastinum. The cause of this mass was a right lower lobe pulmonary primary tumour.
This initial Xray finding was sadly missed by the treating doctor and the reporting radiologist, and only when the patient returned due to increasing analgesia requirements a week later was it spotted. Although diagnosis at the first attendance wouldn't have changed the clinical course, admission for symptom control would have been beneficial; the patient required large doses of intravenous opiates to control his pain.
This case highlights many challenges in patient diagnostic strategies in todays busy emergency departments. Firstly there had been an emphasis on ruling out myocardial ischaemia as a cause of chest pain, and although this is clearly an important consideration it is also important to keep a broad differential when assessing patients in the emergency department. The harmful effects of cognitive bias and heuristics are important in emergency medicine especially when we are making quick decisions in a busy environment. Be aware of anchoring bias which occurs when the clinician prematurely settles on a diagnosis due to important initial features of the presentation and failing to adjust the diagnostic workup when new information is obtained. This can lead to diagnostic momentum bias which leads the clinician down a diagnostic path, failing to acknowledge other potential causes. In this case the potential for myocardial ischaemia as a cause of the chest pain was given a lot of weight due to the paramedics concern for ACS and the LBBB on ECG.
There was also an element of premature closure in this case as once the serial troponins were negative it was thought safe to send the patient home with analgesia and safety netting without consideration for whether there was another rare, life threatening cause.
When reviewing X-rays it is important to look at the whole image each time. When its busy we naturally rely on pattern recognition and probability of abnormality from the history and examination. Make sure you have a systematic approach to reviewing all X-rays to ensure that you don't miss rare and not so obvious findings.
This patient had a primary diagnosis of lung cancer presenting as a metastatic clavicular mass which is clearly very rare, but it is our job in the emergency department to be able to identify the “needle in the haystack”. Through keeping a broad differential, being aware of our potential cognitive biases and throughly assessing patients, blood tests and imaging methodically we will be less likely to miss these rare but important diagnoses and provide excellent clinical care.
For more information on Cognitive bias and heuristics please read:
Incivility affects everyone. How does it make you feel when someone is rude to you? Research shows that mild to moderate rudeness results in 60% reduction in cognitive ability (your bandwidth) following the event. A fine example of this effect is the delayed reaction by your brain when you think about how you should have reacted in the moment when someone was rude to you about half an hour later. And then you feel disappointed that you couldn’t think of this sharp reaction at the time!
Incivility also affects on-lookers. 20% of on-looking staff have a decrease in performance and 50% will have a reduction in willingness to help others. When patients and relatives in the area witness incivility between staff members, 75% will have less enthusiasm for the organisation and 65% will be anxious in dealing with the staff.
Our natural reaction as human beings are to react defensively, perhaps we think of it as protecting ourselves. So, next time when you are trying to refer a patient to another team and you have a rude response, think about your reaction. Before you are rude in return, think about the effect of incivility on the individual and on-lookers and ultimately on patient care and patient safety. Rather than rising to the same level of rudeness, we should appreciate that there may be a reason for the other person’s behaviour and perhaps ask them “Are you OK? You don’t seem like yourself”. Perhaps offer them a cup of tea...
We should not expect rudeness in our day to day professional interactions, and we should certainly not be rude to others. If you're rude, you automatically make your team perform worse.
Please go to the Civility Saves Lives website for more reading
He managed to make it to the shore, get out of his wetsuit, and drive to the emergency department where described severe pain over the suprapubic area. His observations were all within normal range and with analgesia , he managed to mobilise and fully weight bear from wheelchair to bed , although with severe pain.
Examination showed tenderness over the symphysis pubis and the left side of the groin. The abdomen was soft otherwise and there were no other evident injuries. Lower limb examination was normal but range of movement of the left hip was restricted by pain in the left side of the groin.
An X-ray of the pelvis showed evidence of pelvic diastasis, and the left sacroiliac joint was suspicious for a potential fracture. After discussing with the orthopaedic team, a CT pelvis was obtained which confirmed pelvic diastasis with no associated fractures. There was also a 10*6*11 cm pelvic haematoma anterior to and compressing the urinary bladder. Both sacroiliac joints appeared normal, with an incidental cystic lesion noted lateral to the left sacroiliac joint.
The patient was admitted under the orthopaedic team, where two days later, he underwent an open reduction and internal fixation of the pelvic diastasis with a left sacroiliac screw insertion.
This presentation was particularly interesting to consider the possibility of ligamentous disruption to the symphysis pubic with abduction injuries.
N Bothma on behalf of Ahmed Abdelhadi (ED ST1)
This is the CXR if an elderly gentleman, 83 years, who presented in resus after a collapse.
He was found to be SOB and had a CXR:
What do you think: does he need a drain?
On further inspection and manipulating the x-ray:
A guest post by Dr Clair Ashford, Diving and Hyperbaric Physician at the DDRC.
Decompression illness is technically described as a disease of compressed gas divers, aviators, astronauts and caisson workers where gas bubbles form in tissues and/or the blood during or after a decrease in environmental pressure.
However, in ED the main reason you will see it is with divers. They have bubbles of nitrogen in places where they shouldn’t be. They need oxygen – to help the nitrogen clear from the system – and usually recompression as treatment. So, before we get to the technical stuff… please put them on high flow oxygen and call us ASAP.
It can present with pretty much any clinical picture (see below – How does DCI Manifest?). Call us if you are not sure. Diagnosis is clinical and we often speak to the diver to get a history of the dive as there aren’t many diving docs.
We may ask you to do a very thorough neurological examination. Yes, this involves tendon hammers and neurotips, but we do appreciate that these are sparse in an ED. As we are nearby we can see stable patients easily at our unit or come into Derriford ED.
Do not give Entonox (50% nitrous oxide/50% oxygen) under any circumstances to anyone who has recently dived as the nitrous oxide is highly soluble and will increase the inert gas load, making the symptoms of DCI worse. It can also expand within the air filled spaces of the body and cause barotrauma to the lungs, ears, sinuses or gut. Do not give pain killers unless you have a very long transfer to a chamber, and only after discussion with a diving doctor.
Lastly, we might send divers to you and ask for your help assessing whether they have a pneumothorax following a dive. We will ask for your help in deciding this with imaging as you see fit. If they do have a confirmed Ptx with significant DCI symptoms and need recompression, then we may ask for your assistance with a suitable chest drain before transfer.
We are your local Hyperbaric Medical Centre and are very close by:
As already stated…Decompression illness is a technically described as a disease of compressed gas divers, aviators, astronauts and caisson workers where gas bubbles form in tissues and/or the blood during or after a decrease in environmental pressure.
Most divers will come up bubbling.
Please click here to hear some dopplers…
Last week saw the first POTTED session, on hydration assessment and paediatric fluids.
Aimed at all clinical staff, these will continue to run thoughout the autumn.
26th Sept (Stewart room)
24th Oct (Stewart room)
14th Nov (Stewart room)
21st Nov (Paeds ED)
28th Nov (Stewart room)
5th Dec (Paeds ED)
12th Dec (Stewart room)
Clare Bosanko, on behalf of James Dearden
The Derrifoam Blog
Welcome to the Derrifoam blog - interesting pictures, numbers, pitfalls and learning points from the last few weeks. Qualityish CPD made quick and easy.....