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Last week I had the opportunity to attend the 3rd North West Airway Meeting, hosted at the Manchester Royal Infirmary. As well as the chance to listen to some excellent speakers and catch up with people from across the region, I was also lucky enough to have been invited to talk a bit about NWRAG and our upcoming projects (as well as to present an interesting case that I had been involved in). With the focus of the day, rather unsurprisingly, being about all things airway, I hope that these notes highlight some of the interesting points.
Opening
Dr Zuokumor opened the programme with an interesting case report on a case of difficult airway management. It was a nice reminder that there is still nothing quite as good at getting the pulse going than hearing an unfolding story of a progressively difficult airway. The story involved a presentation of a patient with an undifferentiated neck mass that caused quite significant challenges with intubation, included progressive airway bleeding. Perhaps the key differentiating feature of this case was the ability to maintain bag-mask ventilation throughout the case. This really is such a factor in separating the slightly sweaty scenario from the true ‘brown trousers’ one. For me it was fascinating to hear about the use of an awake mask ventilation test, using remifentanil as sedation before a ‘check’ if mask ventilation was possible. However, as noted by Dr Zuokumor, this may have provided him with some false reassurance about the ability to manage with intubation. The use of an awake fibreoptic intubation remains an important option for cases like this, although still remains an imperfect solution. Indeed, the discussion at the end described a case of airway abscess rupture during AFOI, and a subsequently progressively more challenging airway - a worrying reminder that it isn’t always the safest way to manage an airway. Other key important factors identified included the importance of asking for help and the major benefits of having a clear plan in place beforehand to respond to difficulties (learning points that were repeated through the day).
Awake Videolaryngoscopy
Dr Andrew Smith was next, coming down from Lancaster to give an excellent talk about awake videolaryngoscopic (VL) tracheal intubation that followed on nicely from the initial case. Now this is an approach to airway management that I have not yet encountered in clinical practice, although I have seen some comment about it online and discussed the idea with colleagues. Dr Smith delivered a very interesting opening by prompting us to think a bit about how we actually make decisions. As I am sure many of you will know, we are far from perfectly rational beings so this raises some interesting questions around airway management. A case report he presented from NAP4 highlighted how the two anaesthetists involved in a case had completely different management plans, both of which many of us could imagine arriving at ourselves, but of which one had a disastrous outcome. It therefore seems that our decision making is based upon factors other than carefully thought through reasoning, and potentially more on things such as personality, recent experience, current environment and even what is the least effort (let’s just stick in an LMA…).

The link to the topic was that some features of awake fibre optic intubation (AFOI) may be acting as a barrier to its use because of how it feeds into our decision making. Because of its relative unfamiliarity to a number of anaesthetists, as well as the often perceived undesirability for the patient, there may often be enough to convince practitioners that it actually isn’t needed, even in cases when an awake approach probably would be safer. This is compounded by some of the recognised challenges that we have for adequately assessing the airway preoperatively. This is highlighted nicely in this Cochrane review (here) that shows how, although the specificity of many of the airway assessment tests is pretty good, the sensitivity is not. This isn’t really what we would desire in a screening test.

One of Dr Smith’s points was that the use of awake VL may not share some of these drawbacks of AFOI. I think we are all becoming increasingly comfortable with VL, including more than one brand, and so this moves it quite a bit closer to routine practice. If you are interested in reading more about this technique, it is described in an article in the RCOA Bulletin last year (here). Is there much evidence about using it? Well this paper (here) describes a bit more about the comparison of VL with AFOI and doesn’t really identify a clear difference. Overall, this does seem like a very interesting alternative approach to the difficult airway. Although there are some clear limitations (impaired mouth opening is going to be pretty insurmountable challenge), the generally increased familiarity of anaesthetists with VL is advantageous. And the rest of the technique is not that different from AFOI. I did get Dr Smith’s point that this is a skill set that may be easier to develop and maintain that AFOI for anaesthetists outside of major ‘airway’ centres, and as such can serve as a very useful tool for those cases of a potentially difficult airway.  
The Vortex Approach
The final session of the morning was the debate on the Vortex model. Similar to my experience with awake VL, I will confess that the vortex approach to managing the difficult airway is not one that I was particularly familiar with before today. Now I had seen it pop up regularly on Twitter and in the literature, but I was always pretty happy with the Difficult Airway Society (DAS) Guidance; this being the algorithm that I had regularly trained with for a ‘can’t intubate, can’t oxygenate’ (CICO) scenario.

The proside of the debate was well argued by Dr Pete Groom. The advantages described related to many of the human factors that are at play in the horror-show of a CICO scenario. The model of the Vortex can supposedly improve this team communication, providing a shared model for the whole team to work with. The visual representation of the Vortex, along with the prompts included alongside it (suction, neuromuscular blockade, adjuncts). The simulation training he had done with the team as his local site had shown positive results in terms of performance and participant satisfaction with this approach.

Professor Akbar Vohra led the ‘con’ side of the debate. A key opening point was that the DAS CICO guidance still fulfilled many of the advantages ascribed to Vortex. He went back through a number of the previous work on CICO over previous decades and the majority of the messages were the same: recognition of the human factors, train at the basics, prepare appropriately. He argued that the focus of learning should be elsewhere in the process, such as focusing on developing expertise in the core skills involved in airway management. Be a reflective learner, identifying how you can develop competencies to the point of mastery so that these can make the difference in outcome. If you need to use a CICO algorithm, finding a fancy new one is pointless, as this is probably not where the benefits arise. The benefits are more to be gained from not getting there in the first place, and if you do find yourself there, the Vortex model has no clear benefits over the others, such as DAS.

My personal impression is that the Vortex approach doesn’t add much above the DAS algorithm, and being someone who has had most of my CICO training based around this, I don’t see the justification for a change. Having a suitable approach is clearly essential, but I worry that trying to change this approach risks adding additional variability in practice, for little extra benefit, which in itself my impart risk. I will admit that I have no direct experience with using it, and I may find that if I get chance to do simulation with it I will be converted by its practical benefits. Indeed, if we could start again from scratch I appreciate that the Vortex approach is valid, but that is not the current state of things. I will look into it some more when I get chance, but I have just not been able to be convinced of the clear benefit above what we already have.
I was (just slightly) reminded of this comic from XKCD, which I hope you might like.

A link to some further reading on the Vortex Approach is available here.
Research
The afternoon session opened with a short session looking at the topic of research. Dr Gaby Land presented on her investigation into the use of THRIVE in ECT. Even though it is still not fully understood, the use of ECT is on the rise. A small number of these procedures have complications, although the incidence has decreased. It is well recognised that ECT anaesthesia can be challenging due to the remote site nature, as well as the comorbidity that may accompany the mental illness that are the indications for ECT. In addition, there may be an improved ‘seizure quality’ arising from higher oxygen levels. These features suggest possible benefits from the use of THRIVE, by optimising the patient’s oxygenation, reducing alveolar collapse (potentially important in patients having repeated procedures), and reducing the risk of desaturation. Despite the initial discomfort that is often associated with just leaving a patient apnoeic (I know what she means) the results have been promising and are worth keeping an eye out for in the future. Dr Naomi Fleming also gave a short presentation about a project that she is currently looking at in the region around the idea of consent in anaesthesia. I find this a very interesting area given the challenges of getting informed consent on the morning of surgery when the anaesthesia is about facilitating their actual interventional decision. This will be a project to look out for in the near future.

Whilst I won’t go on about it much here, I was very grateful to have the opportunity to attend on behalf of NWRAG and present an update on current and future projects. If you are trainee in the Northwest and have any sort of interest in QI, research and/or audit work, be sure to visit our website to see what activities are going on and what opportunities there are for getting involved. The key one to let you know about is our current project aiming to better explore how we assess frailty in our patients perioperatively (if we do). It’s led by Dr Ananya McCarthy and at the current stage is a fairly straightforward survey investigating clinician understanding of frailty and exploring the systems in place at different sites. We have a number of local leads taking this forward at most sites across the region, but If you haven’t yet heard about this and are keen to get involved please get in touch through our website.
Cases
The afternoon closed with a selection of fascinating case stories. The first talk was from Dr Glyn Smurthwaite as a joint anaesthesia and radiology presentation. This described a variety of challenging airway scenarios, including a massive thyroid mass with tracheal compromise (on top of a mallampati 3, Calder C airway), a traumatic tracheal ‘rupture’, and a retropharyngeal abscess with airway obstruction. Dr Laura Cooper followed with her case of a penetrating airway injury, overlaid by some of the interpersonal challenges of managing an acute problems with a team comprising of a multidisciplinary background, each with different perspectives. Next Dr James Masters presented what is probably the epitome of an anaesthetist’s worst nightmare. A case of acute epiglottitis, in severe respiratory distress in A&E, with an unmanageable airway on the forced RSI, that subsequently progresses to hypoxic cardiac arrest and needing a surgical airway. It was excellent to hear about the effective use of the CICO approach that led to a good outcome, despite the (probably inevitable) emergency surgical airway.

These cases had a few common themes running through them. I think the main one that I want to highlight is that the human factors at play in situations like this are really important. Managing difficult airways, especially with an acute presentation, needs a whole range of non-technical skills, from maintaining situational awareness through to skilled communication within a team. Every time I hear about situations like this I repeatedly think to myself “that would a really good thing to do some simulation on”, and I do think that there are big potential benefits here (although still need to get around to organising anything like this). Whilst some of these skills can really be developed in regular clinical experience, I keep coming across cases which combine a perfect storm of rarity, acuity and ‘speed of disaster’ which makes in my mind makes it harder to apply many of our other skills. I hope to look at simulation in more detail at another time, and given the length of this post already I’ll wrap things up here.
Thank you for reading. I hope there have been a few topic here that have caught your interest and that I have managed to capture the essence of some of the ideas that were being discussed today. And thank you again to the organisers of the meeting for a very interesting day. As always, please leave any comments and thoughts that you have on the topics discussed or any links that you think may be interesting.
BW
Tom
Links & Further Reading
  1. The Vortex Approach. http://vortexapproach.org/
  2. Roth, D. et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev. 2018. https://www.ncbi.nlm.nih.gov/pubmed/29761867
  3. RCOA. Bulletin 111. 2018. https://www.rcoa.ac.uk/document-store/bulletin-111-september-2018
  4. Alhomary, M. et al. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta‐analysis. Anaesthesia. 2018. 73(9):1151-1161. https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14299
  5. North West Research & Audit Group. www.nwrag.co.uk.
Image courtesy of Turmfalke at Pixabay.com.
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This week I attended the PeriopMan Anaemia conference, hosted at the Renaissance Hotel in Manchester City Centre. This was a half day conference focused, rather unsurprisingly, on the topic of anaemia and the impact that is has on perioperative care. For those of you that hadn’t heard of them, the Manchester Perioperative Medicine Society (PeriopMan), are a group based in Manchester with the established aim of bringing focus to collaborative working in perioperative care. Whilst they first started back in 2013, the society as it is now was launched back in 2016. They tend to have an annual conference in October and a further smaller conference at this time of year. To find out more information check out their website: https://www.periopman.co.uk/
The Challenge
Professor Andrew Klein opened the afternoon by asking the questions about why we are actually so interested in perioperative anaemia. The answer is not completely beyond doubt (we are still lacking the highest level of evidence), but there is significant observational evidence on the correlation between pre-operative anaemia and worse outcomes, including both morbidity and mortality. This seems to be correlated with the increased need for transfusion, for which the adverse effects are increasingly being recognised. In cases where it has been aggressively targeted, for example where blood management has been required by law (Italy, Western Australia), the impact on transfusion rate and mortality has been impressive. The confounding here is obvious (I’m sure that there were a number of other changes in surgical technique and perioperative care) but the pattern is pretty suggestive.

Is this actually a big problem though? Well the answer seems to be a resounding yes. There is a decent variation across specialties, but an average of 39.1% of patients undergoing major surgery will have anaemia. And the extent of anaemia doesn’t have to be huge to have an impact -  a threshold of 130g/L seems to consistently be the point below which risk increases. This risk also appears to be a progressive - the more anaemic you are, the higher your perioperative risk. An interesting side note pointed out by Professor Klein here was the impact on women. He described how the WHO definition of anaemia in women was based on a number of population studies in the 1950s; populations which likely included a decent incidence of iron deficiency. The concern here is that a degree of pathology may have crept into the definition of ‘normal’. The problem is that women bleed in exactly the same way as men, and actually the on-average smaller circulating volume compared to men means that there is an increased impact from an equivalent blood loss. This is actually demonstrated in some studies with a demonstrably worse outcome in women. Using separate haemoglobin thresholds for women may therefore be physiologically unjustified and visibly harmful. Indeed, the most recent consensus guidance advises us to just use a threshold of 130g/L to define anaemia, regardless of gender. (https://onlinelibrary.wiley.com/doi/full/10.1111/anae.13773)

Interesting note from Prof Andre Klein: WHO anaemia definition for women based on population data that probably included iron deficiency anaemia i.e. the pathology integrated into what is 'normal', giving the lower threshold #periopanaemia

— Thomas Heaton (@tomheaton88) March 28, 2019
How is this best approached? The answer here seems to be as early as possible, and the challenges that are encountered often come from organisational aspects. The treatment is usually one that will take time to have effect. Iron deficiency is by far the most prevalent cause, mostly on its own but also in combination with other causes, such as anaemia of chronic disease. This needs a period of treatment before the benefit will be seen, ideally at least 2 weeks. This is frequently not the case in current NHS systems where patients may be rocking up at pre-op clinic a few days before their scheduled operation. The case is even more challenging with oral iron. This needs even longer to have an effect and is frequently beset by issues of poor tolerance or simple inadequate efficacy. Even worse, the inflammatory state (which will often accompany a number of surgical pathologies such as cancer) will often elevate hepcidin levels, further impairing enteral utilisation of iron. Oral iron is still recommended by NICE in cases when there is time, but there is a fairly high number of cases where a delay is not going to be suitable, for example cancer surgery. It is here that IV iron has become increasingly employed to optimise the chances of an adequate response in time. ​

Really important point by Prof Klein - Hepcidin levels notably increase after the surgical insult. Post-op oral iron is liekly to do nothing #periopanaemia

— Thomas Heaton (@tomheaton88) March 28, 2019
Implementing Change
There were then some excellent talks about the implementation of perioperative anaemia pathways at a local level, describing how some of these challenges were being met. Dr Iain Gall first outlined his work looking at the anaemia burden in abdominal surgery in Manchester. It was particularly interesting to hear about the relationship between anaemia and CPET; a relationship that I suppose could be expected given the history of EPO (ab)use in some elite athletes. He demonstrated the quite stark impact of anaemia on transfusion practice, with transfusion rates a whole 10 times higher in the anaemic cohort. It’s one thing to be able to read about these differences in journals, but as Iain noted it was quite a different thing to present these results to your own colleagues as a driver for change. A great topic for local QI work.

Dr Rachel Brown followed with another great summary of driving quality improvement work forward in Manchester through their pre-operative anaemia pathway. Through the conception and development of a pilot scheme they were able to show some similarly impressive results in reducing transfusion requirements locally. She outlined some of the challenges faced in doing this, many of which relate to the fairly discordant nature of perioperative pathways currently. As already noted, the timeframe for intervention is tight, and historically the pre-operative assessment has been more about just gathering information rather than doing anything about it. As a haematologist by background, she provided some useful insights into the service and some of the pathways that may be less familiar to us anaesthetists/intensivists which are often needed for day admission for IV iron therapy. Again a theme here was one of resources.  Even the development of a service such as this, with pretty well demonstrated benefits, was a challenge. On the short term horizon the increasingly effective therapies for other conditions, she highlighted an upcoming weekly treatment for myeloma as an example, would likely take up more capacity and lead to further competition for resources.

The final speaker was Dr Caroline Evans. She is a consultant anaesthetist from Cardiff who described a similar story in improving pre-operative anaemia care locally to her. The same challenges were being identified in terms of a high incidence of pre-operative anaemia and the subsequent transfusion demands - her own practice being in cardiothoracic anaesthesia. The implementation of a pathway to tackle this faced a number of problems that had been touched on already. Getting agreement for a policy that involves a wide range of professionals and specialties is no small task, never mind finding capacity to deliver an intervention that needs space, staff and time. These are recurring themes. An example of this being tackled is the attempt to ensure that only a single admission is needed for IV iron therapy, which has triggered a switch to the use of Monofer. Just having to get people to come back for a second infusion, with all the associated demands on services, never mind the impact on patient lives, had quite a detrimental impact on actually achieving the goal of iron repletion.
Final Thoughts
So I had better wrap things up now. I think there are a few key themes that are really worth taking away from the meeting. Perhaps the first one is that this anaemia is a really common problem in patients undergoing moderate and major surgery. This seems to be a clear risk factor for worse outcomes in many ways, for both the patient and the hospital. This is such a good target for continuing the transition from preoperative assessment to preoperative optimisation that the widespread challenges to tackling it seem to be worth taking on. The projects discussed here had already demonstrated reduced transfusion rates, and even length of stay, as well the financial savings described by Professor Klein that would appear to naturally accompany such benefits (iron is not an expensive intervention, blood is). This last point is often a deal breaker in a resource stretched NHS, bumping it up the list of effective but pragmatic interventions that are vying for attention. At the end of her talk, Dr Evans drew the parallel with the idea of marginal gains in leading sports teams. Normalising, or even improving your patient’s haemoglobin levels isn’t particularly flashy or exciting, but the benefits are there. I’m not even entirely sure that the gains are that marginal.

As always please leave any comments and ideas below. I have linked a few useful resources below if you want to read a bit more about the topic. I have to say a big thank you to PeriopMan and all the speakers for a really interesting and excellently hosted afternoon. I’m completing my application for the October event straight away.
Hopefully see you there.
Tom
Further Reading
  1. Anaesthesia. Special issue: Patient optimisation before surgery. 2019. 74(1). https://onlinelibrary.wiley.com/toc/13652044/2019/74/S1
  2. Munoz, M. et al. International consensus statement on the perioperative management of anaemia and iron deficiency. 2017. 72(2):233-247. https://onlinelibrary.wiley.com/doi/full/10.1111/anae.13773
  3. NICE. Anaemia - iron deficiency. 2018. https://cks.nice.org.uk/anaemia-iron-deficiency#!topicSummary
  4. Munoz, M. et al. ‘Fit to fly’: overcoming barriers to preoperative haemoglobin optimization in surgical patients. BJA. 2015. 115(1):15-24. https://academic.oup.com/bja/article/115/1/15/238472
  5. Froessler, B. et al. The Important Role for Intravenous Iron in Perioperative Patient Blood Management in Major Abdominal Surgery: A Randomized Controlled Trial. Annals of Surgery. 2016. 264(1):41-46. https://journals.lww.com/annalsofsurgery/Fulltext/2016/07000/The_Important_Role_for_Intravenous_Iron_in.9.aspx
  6. Australian Red Cross Blood Service. https://transfusion.com.au/
  7. Heaton, T. Iron deficiency anaemia. The Gasman Handbook. 2018. http://www.thegasmanhandbook.co.uk/iron-deficiency-anaemia.html
Image courtesy of LuAnn Hunt from unsplash.com
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I wanted to do some blog posts on topics that have particularly begun to interest me recently - those around medical education. Over recent months, partly through my postgraduate medical education course, I have steadily realised that I have gone through well over a decade of higher education without ever being properly taught how to learn. This is quite a situation to be in with a training program as long as ours, and with a career of lifelong learning still to come. I therefore though I would start by looking at a topic that has really revolutionised my own learning over the past few months. The topic is that of ‘spaced repetition’ and I really don’t think I can understate the impact that it has had on my own retention of certain information. ​
Spaced Repetition
Now I will start by conceding that ‘learning’ as an entity is about much more than the declarative recall of facts (indeed this will be fascinating to explore further at some point). However, as someone who has been doing pretty much continuous examinations for about 20 years, I feel fairly confident in saying that much of our formal education system is still pretty keen on assessing learning by this approach. There is definitely a lot of workplace based assessment in clinical training, but even after medical school, the post graduate examinations involve a hefty dose of recall (I have only recently finished the Final FRCA examination process as an example of this). Now generally I have always found this quite a challenge. I am sure that many of you can relate to my feeling of perfect clarity of thought and vivid insight whilst studying a topic, but how, even by the next day, much of it has already blurred together into an indistinct mental mass. I personally seem to find that generalised concepts survive this decay much better (maybe that is why I like the interacting concepts of physiology) whilst things such as definitions, values or lists seem more slippery to hold on to. My default position since the start of my medical training has been to learn something, forget it, and then learn it again when I next need it (usually the next exam).

So now for the sale’s pitch, for just £9.99 a month, you can learn anything….just joking. As much as some of these benefits are impressive, I’m not quite peddling snake oil. The educational concepts behind spaced repetition are actually pretty ancient. The concept is this; when we learn something, it is surprisingly vulnerable to decay. Ebbinghaus famously described this effect by trying to remember random number, and the resulting graph bears his name (see below). The graph displays what happens to the knowledge that we have 'learned' during the period of time after initial learning.
As we can see, the retention of knowledge displays a negative exponential curve. Pretty depressing! Now whilst we can probably appreciate this in many areas, I’m sure we can also recognise that this doesn’t appear to be the case for everything - some things actually hang about pretty effectively. Whilst there are different factors behind this observation in adult learning, the feature about this that we are interested in is the concept of repetition. As can perhaps be best demonstrated on this next graph, the act of repetition causes a renewal of the ‘knowledge level’ back to full. The big difference is that now this rate of decay is less severe.
The ‘spaced’ in ‘spaced repetition’ comes from the observation that the timing of this refresher session is important. Indeed, the optimal timing appears to be at the point of when you are just about to forget something. Here, the gains in knowledge consolidation are maximised if you revisit the information and refresh your understanding of it. This is a nice overview of the concept of spaced repetition from the team at Osmosis: https://www.youtube.com/watch?v=cVf38y07cfk

Now there is another additional aspect of this which I often group together with spaced repetition - the testing effect. This is the observation that if you test yourself on a concept, you will retain it better than if you simply revise it. This even includes if you get it wrong, as long as there is timely correction. The trick seems to be that it needs to require some effort to get the benefit. As with the spacing mentioned above, if it is just on the edge of being forgotten, more mental effort is needed, it’s harder to do, but the consolidation into long term memory will be stronger. This is another nice video from the Osmosis team about the testing effect: https://www.youtube.com/watch?v=_wqG7g1kZUo
Putting it into Practice
What I do want to promote is Anki. This is one method for incorporating the aforementioned concepts into everyday learning. It is free software (also available in app form) that uses an algorithm to help you test yourself on knowledge, and to space this testing optimally. Think of it as a flashcard deck with an Ebbinghaus curve built in. You create (or can download) an electronic flashcard with a question on the front and the answer on the back, and it goes into your deck. When you open your deck next, you are presented with the questions you have written. Once you’ve answered it, you can click to see if you were right. If you were, you can tell the programme how easy you found it, and it will space the time until it is next presented appropriately, making the gap longer if it was easier (some of my cards have several months between testing now). If you were wrong, it goes back into the deck and will repeat in shortly. You are able to add images and sound as well as text which can be really helpful if you are learning diagrams or another language.

As noted by Chris Nickson in his excellent blogpost on the subject, there are clearly some topics that it will work well for, and others it really won’t. To me this seems to centre around the degree of simplicity: the smaller the package of information to be recalled, the more effective this system. As such, remembering the dose of dantrolene is well suited, whilst the steps involved in performing an awake fibreoptic intubation might be less so. In my most recent Final FRCA exam preparation, there were a few ways that I felt it worked well:
  • Definitions
  • Categories
  • Equations
  • Graphs
  • (Simple) anatomy e.g. brachial plexus line drawing
These are just a few that I have thought of, and there may be many more. I know that using it for learning a new language has great value in developing the vocabulary up at the start, but some of the grammar will not really be tackled by this approach
Why Bother?
But I thought this was more just about passing exams? Well in some respects I think that this is one area where this approach really excels, but I think there is also a very 'real world’ applicability to it as well. There is no escaping the fact that medicine requires you to remember the odd detail or two to practice. It seems to me that many of the things that we deal with on a daily basis (the dose of propofol for instance) will have no relevance to this learning approach. We will simply have already been using repetition, spacing and even testing in our routine activities. It is more the information that is needed, but which will not be given the required consolidation that arises from routine employment of the information. Some examples I can immediately think of are uncommon drug doses and algorithms, or key physiological equations. I'm rarely going to need to bolus a splash of intralipid in my daily practice, but I'd like the have the dose in my mind for when my patient starts complaining that his lips are tingling and his ECG is looking a little odd. You could argue that this might be a rather extreme example of rarity, where the use of a written protocol or checklist is going to be invaluable, and I'd completely agree if there weren't some bad things that happen quite quickly in anaesthesia and ICM. A rare scenario warrants revising before you tackle it, but sometimes there really isn't time and it’s good to know some important details beforehand.

The other argument is one of volume - there is probably a bit too much of this knowledge to constantly be looking up. This is probably the more applicable point for most of us. There genuinely is a lot of this stuff that we learn in exam preparation that is very useful (no I’m not looking at you trimetaphan) but just doesn’t get used with quite enough frequency to know well enough. Examples that I have come across this week include the different lung segments (I’ve been back doing some bronchoscopy after quite a gap), the definitions and normal values of the lung volumes/capacities (revising preoperative assessment of respiratory function) and the normal values of a ROTEM (was performed on a patient in theatre). It is these things that I feel I should know, and will benefit from knowing, but which will not stick in my memory without some concerted effort. As such, nearly all my learning now includes identifying components that I think I will want to consolidate into my memory, and creating simple question and answer cards for my Anki deck.  
Does it Work?
Now this is a fair question, and always a challenge to get incontrovertible data in medical education. There is a degree of enthusiasm out there for this technique (as well as from myself), such as Gabriel from Fluent Forever, and Chris Nickson as previously mentioned. I think that the best summary of this (and several other key learning points) can be found in Make it Stick: The Science of Successful Learning, a book by Peter Brown, Henry Roediger III and Mark McDaniel. This summarises and brings together a huge amount of the work on this topic in a very accessible manner, and I know several #FOAMed guys have also promoted it (hence how I came across it). Over time I’m hoping to look into this and other topics in more detail, and will probably do my usual approach of posting my notes online, so keep an eye out on TheGasmanHandbook.co.uk for more. If I’ve managed to spark your interest on the topic I have included a few other links below which you might find useful for some more information on the topic.  ​
Final Thoughts
Now, I don’t want to try and sound like this is the only thing you ever need to do to study medicine, especially given the great complexities of how we can apply this knowledge correctly into clinical practice. However, in the context of being a tool or a method that optimises long-term retention of large amounts of factual information, I have found both the personal experience of it and the literature around it very persuasive. I suppose the central crux of this post is this: effective learning is hard work. It requires repetition and a sense of mental effort to be most effective. Some of these idea that I have mentioned are just one perspective on this truth about learning, and I hope to explore some more soon. This approach isn’t a silver bullet - it still require the dedicated time of learning the topic and then the additional dedication to go through your flashcard deck each day. However, this sense of mental effort appears to be where the benefits lie, and I’ve been pretty impressed so far. As always, please add your own comments and observations about the topic and any other resources that you think would be useful.

BW
Tom   
Links & References
  1. Osmosis. Spaced repetition. 2016. https://www.youtube.com/watch?v=cVf38y07cfk
  2. Brown, P. Roediger III, H. McDaniel, M. Make it Stick: The Science of Successful Learning. 2014. The Belknap Press. Cambridge:Massachusetts.
  3. Nickson, C. Learning by spaced repetition. 2017. LITFL. https://lifeinthefastlane.com/learning-by-spaced-repetition/
  4. Anki. https://apps.ankiweb.net/
  5. Wyner, G. Fluent Forever. 2014. Harmony Books: New York.
  6. Schnapp, B. et al. Education theory made practical 2: Spaced repetition theory. ICE Blog. 2018. https://icenetblog.royalcollege.ca/2018/04/24/education-theory-made-practical-2-spaced-repetition-theory/
  7. Augustin, M. How to learn effectively at medical school: test yourself, learn actively, and repeat in intervals. Yale J Biol Med. 2014. 87(2):207-212. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031794/
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​Today I was able to attend the RAFT Winter Scientific Meeting, held at the RCOA. This meeting was a great opportunity for the representatives of all the regional trainee research networks (TRNs) to catch up on the events of the past year and look to the future. Despite the snowy weather providing some travel challenges for some of the speakers the day was packed with updates and useful information. I hope to use this blog post to highlight some of the great work currently or imminently going on for anyone interested in getting more involved in research, QI and audit work. 
RAFT Update
The day opened with a general update from the RAFT committee following the recent RAFT survey looking at what was going on in the different regional TRNs. Trainee engagement within the different networks was discussed, with most groups reporting a positive trend in engagement, although significant minority were relatively neutral about this. A very positive note was that there does appear to be a good improvement in the support from deaneries recognising the work done by TRNs, and as such the impact that this was having on trainee interest. The communication within RAFT has generally been perceived as good and the use of Whatsapp and Basecamp programmes, particularly with the DALES study, has generally been effective at keeping everyone up to date.

Further discussion of these topics through the day was interesting and useful. A well-recognised problem was the competing interests that exist for trainees’ time, and thus the number of trainees getting involved with TRNs. It was noted that there may be some national guidance coming on trainees being able to use SBA time in a more personalised manner, particularly outside of key exam years. I personally think that a discussion about the ability to use training time in this manner could be a big draw for trainee involvement, especially as such training/ARCP requirements are often being completed in trainees spare time. This does still seem to be a significant challenge but hopefully the increasing recognition of the quality of the work that is being done, such as the size and scope of the DALES project, will continue to be a draw for trainees. With trainees already working so hard, it is difficult to ask for additional free time to be sacrificed, no matter how interesting the projects are.

This topic of engagement was touched upon again later in the day. Charlotte Small delivered a presentation on some of the work of the West Midlands TRN (WMTRAIN) on promoting trainee engagement in their region. They had created a number of videos introducing their network, giving a brief introduction to what they were about. They felt that this was a useful and helpful approach to advertising and promoting the network over a large region, especially compared to ‘in person’ promotion at the different hospital sites. This was a particularly nice way of distilling the concept of trainee-led research and audit into a clear message.  
Projects
Following the NWRAG involvement in delivering the DALES project in the Northwest, it was exciting to hear an update on the most recently conduction RAFT project. There were many positive points taken from the running of the study itself. The electronic data collection process was relatively novel and proved to be effective, flexible and secure. The result was an almost 100% digital workflow for data collection with no major technical issues during the trial period, and only some connection issues during the pilot. This digitalisation has proved to be a big benefit for tracking accruals and is a nice step away from the reams of paper that has often been previously needed. In a similar way, the use of verbal consent and electronic ‘tick box’ confirmation was relatively novel and proved to be very acceptable to staff and patients (a concern that had been previously discussed). The result was 1500 local investigators recruiting 26,000 data sets from 214 sites across the country (a massive study for consenting patients in anaesthesia). The data are still being tidied up prior to statistical analysis and it will be interesting to look through the results.

Tim Cook then gave an overview of the processes behind the NAP projects in particular looking at the challenges in getting them completed. A key point was the size of the studies - for example, NAP5 essentially doubled the case numbers on anaesthetic awareness in the medical literature. It is partly this size that makes them so valuable but requires a significant effort. A major part of this has been the engagement of clinicians throughout the country who have allowed it to work, a similar factor in the success of the RAFT projects. The primary goal of NAP is to produce a better knowledge of harm and thus improved information for patient. This study approach is well suited to answering the question that is being posed, where the events are so rare that and RCT approach is impossible. Despite their rarity the seriousness of the events is a big factor of interest for anaesthetists. Indeed, the design of the NAPs is that they are chosen, funded and performed by anaesthetists, which is perhaps why the topics that have been picked feel so relevant. Whilst wrapping up he used the term ‘citizen science’ to describe this widespread engagement of clinicians who aren't 'researchers'. I really like this term to highlight the ability for non-research clinicians, especially trainees, to participate in meaningful, large scale projects that can make a positive impact for patient care.

There are a couple of other major national projects ongoing that are of particular interest to RAFT groups. The FLO-ELA (Fluid optimisation in emergency laparotomy) project is currently ongoing and really benefiting from trainee involvement. The concept behind this project is that currently we don’t have a good idea what to do for fluid management in this cohort of patients. These patients are probably different from both the elective laparotomy patient and the patient with sepsis which have both been studied.  Given the number of emergency laparotomies that happen out of hours, the involvement of trainees in recruitment is really helpful. More information is available from their website here: https://www.floela.org/

A final project that was presented was the Perioperative Quality Improvement Programme (PQIP). This is a national programme that aims to look at the perioperative care that is being provided and then providing local data back to participating sites to aid local QI work. Data is collected locally from certain patient groups, submitted to the PQIP database and a lot of this is then collated and returned by the PQIP team to aid this process of QI locally. Measures include parameters such as the number of patients receiving the different ERAS components, and the number of patients meeting targets such as drinking, eating and mobilising on the first day after surgery. I continue find this project very interesting because of the QI focus of it, giving it some very immediate utility for the vast majority of hospitals. As has been done at some sites, the PQIP work can be used as a foundation for more specific local project of interest e.g. looking at perioperative anaemia. This seems like such a good starting point for many different sorts of QI work that it is something I am quite interesting in finding more about. More information is available here: https://pqip.org.uk/content/home#
Groups
The day included an update from a couple of the non-regional trainee networks. The PAIN-TRAIN gave an update first. They are a geographically diffuse network of trainees with an interest in pain medicine. They recently finished their first big study, GABACUTE, looking at the use of the gabapentinoids in surgery. This included a survey of anaesthetists about their beliefs and practice. More information is available from their website: https://www.paintrainuk.com/

The TRI-STAR team also provided an update on the work of their developing trainee network. They are another geographically spread-out trainee network of military trainees. They have started with a few smaller studies, including exploring the role of peripheral nerve blockade, and are looking at developing future projects. 

Next the Paediatric Anaesthesia Trainee Research Network (PATRN) team talked about their special interest network (https://www.apagbi.org.uk/professionals/trainee-section/research-network-patrn). They are part of the Association of Paediatric Anaesthetists (APA) and have undertaken a few projects since their 2015 inception. The biggest has been the PAPAYA study which looked at unplanned admissions of paediatric patients after day case surgery, recruiting nearly 24,000 patients. They are currently preparing to deliver the PEACHY project looking at the impact of obesity on adverse perioperative respiratory events.

Finally, James from the STARSurg team talked about the work of their surgical network. Developed as a more student focused research group, he talked about how they were set-up to promote medical student involvement whilst still ensuring the support of senior clinicians. They have done some pretty impressive collaborate work, including on an international scale, as well as other work promoting research skills (HACK days). They have just started their next study, RECON, looking at postoperative pulmonary complications following abdominal surgery. More information can be found at: https://starsurg.org/
Final Words
​Overall then it turned out to be a pretty packed day with a wealth of information and inspiration for all us from the different TRNs. Hopefully there are some topics there that spark some interest, and if so I would encourage you to check out the website of your local TRN, a full list of which is available on the RAFT homepage. I know I have taken note of a load of stuff for back up in the northwest and continuing with some of the work we are already planning, so check out our site at www.nwrag.co.uk. If you have any comment or thoughts, please don’t hesitate to pop them down below or get in touch with one of the TRNs through their respective site.
BW
Tom
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Last week I had the chance to attend the inaugural St. Emlyn's Live day in Manchester (#StEmlynsLive). The day proved (as expected) to be a fantastic collection of talks and ideas on Emergency medicine, critical care, medical education, and the surrounding factors involved in being part of this profession. With a wealth of learning points to take away, I wanted to put a few of them together in a blog post. Many of the topics will be covered (or are already covered), both better articulated and in more detail at their own blog and other sites, but there were a few parts that were my favourite. When looking back ad considering the bits that I took away, I would probably break them down into a few key themes:
  • Striving for excellence
  • Innovative thinking
  • Clinical pearls
Excellence
The topic of striving towards excellence was a common theme throughout the day, with many of the speakers covering different aspects of it - unsurprising with it being the first of St. Emlyn’s philosophical pillars. Natalie May (@_NMay) opened the day, bringing back pearls of wisdom from her work in Sydney HEMS, something that Clare Richards (@drclarebear) revisited later in the day. They both covered features of the setup at Sydney HEMS that allows excellence to really flourish. One of the standout parts for me was the normalisation of debrief that was so fully integrated into the way that they conducted their service. Cases, even more ‘mundane’ ones, were routinely discussed to identify learning points. All of this as part of striving towards delivering a better service for patient.

Within this nebulous term of ‘excellence’ though, there was repeated reference to the components that were the more tangible components in day-to-day practice. The aforementioned morbidity and mortality (M&M) meetings, the contrasting discussion of ‘excellent practice’, the leg-work of audit and governance structures, and of course the training, were all highlighted as the very achievable components of a system that is working towards excellence. For me, this reiterated the fact that much of this talk of ‘striving toward excellence’ is far more than just aspirational thinking. I think that these are all components of our normal clinical practice that we may partake in less fully, or see as lower down the hierarchy of importance when we are at the clinical coalface, but which may be the building blocks of a better system. Now I can see that the criticism may be that it is all very nice talking about these ideas over coffee at a nice conference, or even delivering them in a system with a predictable degree of down-time, but how can I fit in a weekly M&M session when system is as stretched as it is currently? Well I think that the next clinical theme gave me hope.
Innovative Thinking
Simon Carley (@EMManchester) opened his talk with pretty much a summation of this concern. It’s nice to hear about these ideas, and in many ways it is inspirational, but it is hard to the make the translational step when you go back to the clinical job the next day. As such, his talk, as well as facets of several others, were about the ‘low hanging fruit’ of improvement. The life-hacks and tweaks that can be implemented with little or no funding, planning, or even that much effort. The particular topic that he was covering was around resuscitation practice, and he presented his ‘top 5 tips’ for streamlining and optimising your clinical care, without needing to learn how to deliver REBOA or getting a departmental ECMO machine. He has written an excellent blog on the presentation here and goes into more detail about the zero point survey here. The concept of ‘hot debriefs’ was an idea that particularly caught my eye, as debrief is still a practice that I struggle to complete with any degree of regularity. All simple, easily implementable strategies that any one of us could bring into our workplace the next day.

In a slightly different vein, but just as inspiring, was the fascinating talk from Kat Evans (@Kat_Evans). She delivered an eye-opening account of the challenges faced by her and her team working at her hospital in South Africa. What was perhaps most inspiring was the adaptations that they had innovated to meet these challenges. Faced with a high number of thoracic stabbing wounds and limited resources, she described their triage system for coping with such large numbers: top off at the door, ultrasound/echo, the chest drain room for those with pleural injury, thoracotomy in the ED for those that needed a hole in the heart fixing. And the speed of the turn-around was just as amazing. No languishing in hospital beds, but instead kept mobile and active (including an exercise bike in the ‘chest drain lounge’). Even the enhanced recovery programme physios aren’t quite achieving this level yet. Now I know that these are all (mostly) fit young men, but along with some of the perioperative medicine stuff at the moment (the enhanced recovery programme being an example of how ‘normal’ care has progressed), it does make you wonder which aspects of our own practice are actually superfluous, and even unconsciously harmful. Innovative responses to challenges like this suggest that different models might not necessarily be what they first appear.    

In another contrasting direction, Rick Body (@richardbody) gave a fascinating talk on what may be in store for the future of diagnostics. He covered questions that continue to challenge me - how can we use what information we have to make the right decisions? Whilst not completely handing medical care over to AI just yet, he described how we may soon be able to use big data, user friendly apps and point of care (POC) testing to navigate the branching paths of diagnostics. There is even a fancy new term; theranostics, precision medicine where the diagnostic test can guide treatment. Whilst the old challenge of chest pain was the central narrative of his talk, there was even a reference to POC genetic testing in the ED! If ever there was a talk to get you more excited about involvement in research, I think this one would take some beating. Some of the themes from his talk are covered a bit more one his blog post from earlier this year (here).
Clinical Pearls
Whilst we await these technological changes, and think about some higher level strategies to improve our care and the way it is delivered, there were also a few talks on some clinical challenges that we may face. George Willis had some great points on managing aortic nightmares, including tips on the best way to perform pericardiocentesis (!) - the tip is to not take too much blood off at a time. Similarly, Salim Rezaie (@srrezaie) did an excellent talk on going beyond Advanced Life Support (ALS) to improve our resuscitation care. Key point included considering using mechanical CPR devices where available (not worse and can allow cognitive offloading), the quality of human delivered CPR is very important (how often are we actually assessing this during an arrest?), and thinking about how ultrasound scanning can be implemented into identifying reversible causes of arrest, but without negatively impacting on CPR. There is a lot more of what Salim talked about available here: http://rebelem.com/beyond-acls-cognitively-offloading-cardiac-arrest/
Now I feel that I have barely scratched the surface of the topics of the day, but in the interest of attention spans I think I will finish this blog post here. I strongly recommend having a look at some of the other references from the day which I have listed below and will try and add to. I hope this post has served as a bit of a taster for these topics, and at the very least directed you towards some interesting ideas and resources. In the spirit of the day, I will now need to think how I can implement all these ideas.

Thanks for reading.
Tom Heaton
Further Reading
St Emlyn’s Blog - The home of it all - https://www.stemlynsblog.org/
SMACC - Social Media and Critical Care - https://www.smacc.net.au/
Bad EM blog - Brave African Discussion in Emergency Medicine - https://badem.co.za/
R.E.B.E.L. EM - http://rebelem.com/
ED Educate - a nice summary of the day - https://www.ededucate.co.uk/blog/st-emlyn-s-live
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