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
This is the presentation I gave at the ED Wellbeing day back in the summer. It is also available as a webinar on the Trauma Care website, and we discuss similar themes in this podcast. I have been inspired by several other people to produce this blog, and if you would like to know more I suggest you find them on Twitter, where you will find links to their FOAM resources: @emcrit, @DocTomEvens, @HumanFact0rz, @ResusPadawan, @EMSwami
Firstly I would like to emphasise that this blog is concerned with the ability to perform when faced with acute stress, not chronic stress or post-traumatic stress disorder.
The reason we, as humans, have a response to stress is the innate 'fight or flight' reflex which kept our ancestors alive. But the very design that gave us a survival advantage as cavemen, unfortunately has deleterious effects on our ability to perform under stress, when what we really want to do is run away!
A little bit of stress is a good thing?
In 1908, Robert Yerkes and John Dodson presented their ground-breaking research on the non-linear nature between arousal, based on task difficulty, and brain functioning. Focused/in-the-zone is a good thing. Performance improves when you are ‘a little bit activated’. But we need to be aware that this is not exponential – and recognise when performance tapers off.
There is a really interesting book on this subject by Lt. Col Dave Grossman, called 'On Combat'. It discusses the effect of stress on performance in the context of ‘deadly force encounters’ amongst military and armed police, and provides huge insight into the way in which stress could affect performance in medical staff too. Listen to this Emcrit podcast to hear more.
Performance Deterioration as a Function of Heart Rate
From On Combat, by Lt. Col Dave Grossman – former US Army Ranger & paratrooper
The deleterious effects of stress on performance are profound and pervasive. The time taken to complete manual tasks is doubled under stress conditions.
In addition to the physiological consequences of increased heart rate, breathing rate and tremor, there is also an emotional and cognitive burden.
We feel fear, anxiety, frustration, and lose motivation.
We have a narrowed attention, decreased search behaviours, longer reaction time to peripheral cues, decreased vigilence, degraded problem solving, performance rigidity.
There are changes in social behaviour: loss of team perspective, decrease in pro-social behaviours such as helping, obliterate ability to share mental model.
Acute stress causes a doubly-whammy in terms of potential error, it erodes decision-making and situational awareness, and reduces team performance; so the individual is less receptive to suggestions from others, which would normally provide a safety-net.
Why do we feel stressed?
Before we can enhance our performance, we need to understand what causes us stress.
A process occurs by which environmental demands (eg performing in front of others, taking an exam) evoke an appraisal process in which perceived demand exceeds resources, and results in undesirable physiological, psychological, behavioural or social outcomes.
If the individual determines that his or her resources are sufficient to meet the demands of the situation, the situation is appraised as a challenge and the potential for gain (i.e. elevated self-esteem, learning) is recognised. If the resources are not judged to be sufficient, the situation is appraised as a threat because of the significant potential for loss. Socio-evaluative stressors (when behaviour is potentially judged by others) and uncontrollable situations are more likely to be appraised as threats than challenges.
What can we do about it? In advance...
We need to move into a Challenge rather than a Threat mindset.
Think about how you can increase your resources:
Stress inoculation training (SIT) is a three-phase cognitive behavioural training approach to limit the impact of acute stress on performance. SIT has been used to decrease the perception and influence of stress – or promote ‘stress resistance’ – across a variety of domains, from public speaking to combat aviation. Have a read of this blog/listen to the podcast for more information.
1. Conceptualisation-give a background of stress responses, why they happen, and what to expect.
2. Train and educate on the skills and tasks we want to see performed under stress. Then give the tools to deal with the expected stress.
3. Do a dry run to train in simulation without added stressors
4. Run the same training with stress inoculation
Your brain is the most powerful simulator you have.
Mental Practice is the mental rehearsal of activity in the absence of gross muscular movements; it has been demonstrated to enhance acquisition of technical and procedural skills. It has been shown to improve performance in basketball and piano players, to a standard equivalent to them having physically practiced performing the procedure, and there is evidence to support the same in the medicine.
What can we do about it? On the day...
Tactical breathing. Take a deep breath in for 4 seconds, hold it for 4 seconds, breath out for 4 seconds, hold for 4 seconds. Repeat. This combats the physiological affects of stress, and moves you down the combat stress performance graph.
Positive self-talk is used by athletes and any elite performance group.
Visualise yourself performing the task exactly how you want to see it done.
Your own perceptions are important:
Recognise your own stressors, beware of going into it with negative thoughts
Think about when you did it well, visualise success
Change your negative into positive thought (exude confidence, for both your patients and your trainees) 'Calm is contagious'
Accept the fact, but reject the premise. Yes I was unsuccessful last time I performed this procedure but that doesn't mean I cannot be successful this time.
What is anxiety?
It is a psychological and physiological state characterised by somatic, cognitive and behavioural components.
And it is a BIG problem....
I suppose this is not surprising, and our Emergency Department is just as bad, if not worse, than an anaesthetic room: it is an alien environment, there is lots of frightening equipment stuff, and people rushing about! Children may be pushed beyond their capacity to cope.
Our job is to help children cope with anxiety and reframe it so that it does not become crippling. But how?
Communication is key.
Advanced communication techniques fall into two groups
Example: "Hello James, come in. I love your shoes, reckon they'll fit me? I reckon they're too small but what's size between two friends? I'd probably bend them if I wore them, but not like Beckham though. He's a good player, better at United than Real, the real deal in red not white I think. Red devils are United, but they're heavenly players, making music on the pitch, perfect pitch but I'm tone deaf even though I love to sing in the shower. Not the rain shower, though Singing In the Rain is a great film, but water in the camera is bad news, it makes the colours run off the screen, right off track but listen to me I'm like a stuck record."
Behaviour, non-verbal, verbal or tactile usually associated with having rapport where as yet that rapport does not exist.
Bind of comparable alternatives
Free choice of two or more comparable alternatives, and whichever is chosen leads to behaviour in the chosen direction. Usually feel bound to accept one alternative.
Use with caution and be inclusive and appropriate
Methods to reduce anxiety and pain by focusing on something else
Want to know more?
Please consider going on the course - see their website
ACCS teaching this week was on the topic of Vertigo & dizziness, we thought it would be useful to share some key points with a wider audience, and point you in the direction of some great resources, particularly the RCEM Learning module on the topic
What do patients mean when they say 'I feel dizzy'?
1 Vertigo an illusion of motion of either the subject or the environment
2 Presyncope a feeling of impending faint or loss of consciousness
3 Disequilibrium impaired balance and gait in the absence of abnormal head sensation dizziness of the feet
4 Light-headedness a non-specific description of symptoms that cannot be identified as one of the above types
3% of patients present to ED with dizziness/lightheadedness/imbalance, which equates to approximately 9 patients per day to our department, and the literature states that up to 28-59% of posterior strokes are missed in the ED.
Vertigo is defined as an illusion of rotatory movement and always implies an imbalance in the vestibular system although the symptom doesn’t indicate where the imbalance originates. Around half of patient presenting with vertigo have peripheral cause.
Anatomy & pathophysiology
Sensory inputs from the vestibular apparatus, visual system and proprioceptive stimuli from the neck and rest of the body. The vestibular apparatus consists of the membranous labyrinth contained within the bony labyrinth lying in the petrous temporal bone, which connects via the vestibulococclear nerve to the vestibular nuclei in the brainstem. These nuclei interconnect with neurones in the cerebellum, spinal cord and cerebral cortex.
The membranous labyrinth consists of the three semicircular canals and two chambers, the saccule and utricle. Flow of fluid (endolymph) in the canals stimulates cilia attached to a sensory organ located in the ampulla of each canal, the crista ampullaris. In the saccule and utricle, movement of calcified calcium carbonate crystals (statoconia or otoliths) stimulates cilia of another sensory organ, the macula. Therefore movement of the head in any plane modifies neural impulses transmitted via the vestibular nerve, connected to each of the sensory organs, to nuclei in the brain stem. Vertigo results from an imbalance of either the received signals or information processing in the brainstem.
Vascular supply is from anterior inferior cerebellar artery and posterior inferior cerebellar stray. These are branches of the basil artery and vertebral artery - the posterior circulation.
When assessing a patient with dizziness...
Establish that it is vertigo and not one of the other symptoms. A multitude of medical problems can cause lightheadedness/presyncope - these need to be explored and investigated differently (VBG/ECG/BP will be useful in this regard).
1. Onset: rapid vs insidious
2. Associated symptoms e.g. nausea/vomiting (more common in peripheral causes), tinnitus + deafness (both suggest Menieres)
3. Effect of head position on symptoms: exacerbated movements of head and then settles (suggests BPPV), exacerbated by movements of the head but persist (labyrinthitis, vestibular neuritis), not affected by movement of the head (central cause)
5. Recent local trauma (consider possibility of vertebral artery dissection if any preceding neck pain) or infection
6. PMHx: particularly for stroke risk factors
7. DHx: ACE inhibitors, amiodarone, aminoglycosides, beta blockers, cocaine, phenytoin, salicylates, sildenafil may all cause vertigo
1. Ataxia (suggest central cause)
2. Nystagmus: Peripheral – horizontal, fatiguable, surpressed on visual fixation, unidirectional, fast phase beats away from pathology
3. Cranial nerves, including hearing assessment
4. Peripheral nervous system
5. Check for cerebellar signs (DANISH = Disdiadochokinesis, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia)
6. Ear examination
7. Consider undertaking a HiNTS examination - for more on this have a look at this St Emlyns blogpost, the paper it references: doi.org/10.1016/j.annemergmed.2017.10.012 and these YouTube videos
8. For patients with suspected BPPV, consider undertaking a Dix-Hallpike and then Epley manoeuvre, for more information have a look at this EMJ letter: doi:10.1136/emj.2010.105874
Want to know more?
Please have a listen to this podcast from the excellent people over at FOAMcast
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.....