#badEM (Brave African Discussions in Emergency Medicine )
Brave African Discussions in Emergency Medicine #badEM is a group of long time friends that all support a passion for emergency medicine and FOAMed. They are all about promoting the special uniqueness of Emergency Medicine in Africa.
Day 3 Pain Management Introduction was taught/facilitated by Dr Rene Kraus. I will in the future post my version of the “Pain Masterclass” when we do an entire section of the Diploma on pain management..
When thinking about how we can stop pain in its tracks: we have to think in terms of ascending & descending pathways..
Different drugs work on different parts of the pathways, BUT pain is experienced by people & families not nerve pathways!
Pain is experienced TOTALLY, and we need to modulate it TOTALLY.
NB: The amount of pathology does not equal to the amount of pain.
Pearl of wisdom from Rene: some patients with chronic pain/illness claim to be coping well independently.. have a look at their toenails.. can often give clues on how well the pain is ACTUALLY affecting their functioning!
I would highly recommend my classmates & people interested in dealing with chronic pain in the Emergency Centre / Primary Healthcare / Palliative Medicine watching the below 2 talks by badEM’s friends Iain Beardsell & Rowan Duys.
I have made the decision to put my student hat back on and start a 1 year Postgraduate Diploma in Palliative Medicine through UCT this year. Day 1 discussions were facilitated by Dr Rene Kraus. Our class are a fascinating group of largely very senior/experienced palliative medicine doctors/nursing staff/allied health colleagues. I am excited to collaborate and learn from the group
History of Palliative Care & Hospice
Hospice traced back to medieval times:
“The first hospice or monastery was built in the 9th century at Bourg-Saint-Pierre, which was mentioned for the first time around 812-820. This was destroyed by Saracen incursions in the mid-10th century, probably in 940, the date at which they also occupied Saint-Maurice. Around 1050, Saint Bernard of Menthon, archdeacon of Aosta, regularly saw travellers arriving terrorised and distressed, so he decided to put an end to mountain brigandage in the area. With this in mind, he founded the hospice at the pass which later bore his name. The church’s first textual mention is in a document of 1125. The hospice was placed under the jurisdiction of the bishop of Sion, prefect and count of Valais, thus explaining why the whole pass is now in Swiss territory.” – Wikipedia
Where did the concept of ‘Palliative Care’ come from? Dr Balfour Mount from Canada proposed the word palliate, which comes from latin word Pallium which means cloak, because symptoms are “cloaked” or “disguised” with treatments whose primary aim is to provide comfort even if cure is not possible.
Palliative Care Principles – WHO Definition:
Palliative Care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual….[click here for further part of WHO definition]
Dr Kraus unpacked the above definition for us into its components:
What is QOL? Depends on individual values, presence and absence of certain symptoms. QOL is fundamentally unique to each individual! Don’t apply your version of what good quality of life is to your patients.
What is a family? Legal family vs the people the patient perceives to be family.
What is a life-threatening illness? Difficult to define and very important to base on your context. Interesting in the international oncology discussion on this topic they spoke about ‘progressive metastatic cancer’, an African oncologist asked that instead we change this to ‘metastatic cancer’ due to different management strategies/interventions available. The SPICT Tool is useful in this regards BUT remember doesn’t mention TB/HIV which is key in our setting.
What is suffering? Suffering (patient, family & community) is multi-factorial. Important that suffering & discomfort are not the same thing. Discomfort may be normal or actually necessary.
What is spirituality? We will discuss this at a later stage.. as we are doing an entire week theme on it.. Important to understand that Spirituality does not equal Religion.
Some thoughts/discussion points brought up regarding the definition: Important that not only TREAT suffering, but PREVENT suffering in the first place. Dr Kraus alluded to when her interest in PC began, which was working in rural SA in the height of the AIDS pandemic when ARVs were not yet available. At that stage there was no treatment option available. Something that is discussed a lot in EM circles.. regarding dying as a normal process. Using the “natural death” terminology. We discussed that dying and death is a process/journey not an event.
Palliative Care: YOU Are a BRIDGE - YouTube
Will try and post regular “African” context Palliative Care pearls as the Diploma proceeds
The below are some random thoughts extracted from my talk at AfCEM 2018 Conference:
Don’t forget your audience is worldwide not all in the same healthcare context as you – think about your influence.
Sometimes flippant comments/assumptions are made by authors that when read by a clinician from low resource context, renders them despondent & confused, instead of motivated & inspired.
Ask LMIC clinicians to be involved to peer review posts. May have surprising feedback/suggestions!
For every post/material the author should cognitively force themselves by asking “how does this apply to low resource settings, is it necessary to specifically mention resource considerations”
Consider loading one year’s worth of podcasts/videos onto cheap flash drives and sending to registrar/residency training programmes around the world.
Try list a resource’s (e.g. video/podcast) actual size next to download button, so someone doesn’t have to click download and then cancel quickly when they discover it is 500MB !
Compress files to as small as possible, does the image REALLY have to be that hi-res?
Keep short, or if long try to split into components e.g. Part 1,2,3 (we understand sometimes this is tricky).
Consider text summaries of podcasts.
Ensure downloadable, not just streaming, so that videos can be shared via flashdisks etc. to colleagues.
When loading videos up to Youtube, you can set what the lowest quality available for viewing is.
If you put a lot of stats/words into infographics, try set the ALT-text in such a way that if reader is viewing website with images switched off, they can still engage with your writing at this level of detail.
Summary notes on talk given at AFCEM 2018 “Ten Commandments for getting your research published” by Dr Ellen Webber, Editor in Chief of Emergency Medicine Journal @emjeditor
A large proportion of studies/research is not published. Improve your chances of getting your chances noticed. Put your best foot forward from the beginning.
Always use a research checklist
Checklists assist you not only to organise your paper, but also to plan your research study. This also ensures that you collect all of the data from the outset. You can get more information and all checklists at the Equator Network, here.
Read and obey the instructions for authors
Does your article fit the mission of the journal and do they have a relevant article type for your research? Make sure you have met the requirements for each section.
Sell your research question (in the introduction)
Outline the problem (not lack of knowledge), and say why it is important (the problem, not your study) and what the knowledge gap is. Mention how your study helps the situation of the identified knowledge gap. Avoid taking too long to get to the point of your research question, keep it short. The whole introduction should lead into your research study.
Honour your methods
This is actually the most important part of your manuscript. The methods should demonstrate that you have done your study well by putting in enough detail that your study can be replicated from scratch (and use a checklist to guide the detail). Using sub-headings can assist with this.
5.1. Results: Who before what?
Begin with the demographics of the patients/participants that were involved in your study and this is normally reported in Table 1. If you lost patients to follow-up or similar be sure to show the demographic information of the group that was excluded to show that there was no selection bias.
5.2. Results: Match your methods and discussion
Make sure that you do not quote results that were not reported in your methods and vice versa. Do not use results in the discussion that was not reported in the results. Do not provide an interpretation of your results here. Stick to the facts only.
Discuss and don’t ramble
Provide a brief, plain English summary of what your most important findings are – no numbers – here in the first two sentences of your study. Contextualise your study and mention how your results or study is different from previous studies and how you add to previously published literature. In addition, can you explain why you are observing this. Here, you can especially highlight how your results (from the LMIC setting) is different from other studies (from HICs).
Discuss the limitations plainly and honestly. Mention explicitly the implications of your study (think press release). The implications should be specific and if “more research is needed” mention exactly what should be asked or done.
Sell the research question, but not the result! You should set up the question so that a positive or negative finding is important. Do not try and spin negative results either! Interestingly, negative data are often statistically more trustworthy than positive data.
Revise the abstract
Provide a short but compelling background statement. Your methods should generally be longer (dates, setting, inclusion criteria, outcomes and your type of analysis). For the results, firstly mention who is in your study and provide the result of your primary outcome. Your conclusion should in one or two sentences summarise your main result (as in the discussion) and one sentence regarding the implications of your result.
Give your paper to someone for constructive criticism who knows nothing about your study, but something about your field.
Check your work
Check for typos and grammar issues by reading it without track changes. Make sure your tables match text and that your references are complete and in the format of the journal. Make sure that your word counts are in line with the author instructions.
Submit and submit again
You have an ethical obligation to publish and disseminate your research. Research suggests that the number of submissions is not related to the quality of the research study. Most authors are not published because they give up too soon. Peer review should be considered as free mentoring, and learn from your mistakes.
[Note from the blog editors: Interesting discussion in questions afterwards about researchers who are not first language English speakers. Need to find mentors who are willing to look at language NOT be authors on papers! There are paid services for this but there are other options such as Authoraid. https://www.authoraid.info/ If you are looking for help on your paper or are willing to assist authors please check them out! You may also want to look at the authorship guidelines by the International Committee of Medical Journal Editors that outline the conditions for authorship contributions on a research article, here.]
When Kat Evans came and spoke at DFTB17 on the state of emergency medicine in South Africa she was all abuzz about this new conference that the badEM crew were going to put on. As she had made the effort and travelled all the way to Australia I thought it only right to return the favour. I’d said that I was happy to speak about “anything paediatric” but I think the team only read the word “anything”.
I’d often written about the importance of the soft skills in medicine but to talk about “How to be kind” and in just 15 minutes? That was a real challenge.
So I delved into the literature about the benefits of kindness – to ourselves and to others. I found out how it made us live longer, healthier and happy lives and I came up with a way to frame it so we could all practice a little kindness every day.
Put your notes down and pay attention to the person in front of you. Commit to giving them your time and attention.
Actually look at your patient – look them in the eyes. We make hundreds of non-verbal cues every minute. If you don’t look at them then you won’t see them.
Don’t interrupt. Doctors generally interrupt their patients within 18 seconds of the start of the consultation. Try to listen without judgement, allow the patient to talk out their piece and clarify your understanding of the situation.
Everyone has a story to tell. To most of our patients this visit to the doctors is the most important thing that will happen to them this year, if ever. Try and put yourself in their place.
Just by doing these four things then we can be a little kinder – to our patients, to ourselves and to our partners.
Watch the full presentation from the conference below!
If you want to know more then you can read my blog posts on the why and how of kindness over at www.dontforgetthebubbles.com
#badEMfest18 - Human/Kind - Andrew Tagg - YouTube
Andy Tagg is an Emergency Physician with a special interest in education and lifelong learning. Andy is one of the founding members of the excellent pediatric blog Don’t Forget The Bubbles. Read more from Andy here.