Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact
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About Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact

Tasty Morsels of EM 046 – Reactive vs Gonococcal Arthritis

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

REACTIVE ARTHRITIS

  • You probably used to know this as Reiter’s Syndrome (at least it was when I went to medical school) but it has gone the way of Wegener’s and had its name changed due to the Nazi associations.
  • usually 2-6 weeks following infection
  • GU or enteric infections
    • GU: chlamidiya (remember chlamidiya less likely to have urethritis symptoms than gonococcal)
    • Enteric: Salmonella, Shigella, Yersinia, or Campylobacter
  • both have asymmetric arthritis, knees, ankles feet and heels most often involved.
  • can also have conjunctivitis and even uveitis
  • up to 10% can have painless ulcers of mouth and tongue which can later become painful shallow ulcers, penis can also be involved.
  • look for dactylitis (remember this also occurs in psoriatic arthritis)
  • NSAIDS work well for both
  • antibiotics work for chlamidiya associated cases but not enteric ones

GONOCOCCAL ARTHRITIS

  • gonocoocal arthritis the most common cause of septic arthritis in sexually active population
  • more females than males
  • does not present the same as classic septic arthritis and much less chance of joint destruction
  • can be split into two syndromes that overlap
    • oligoarthritis (usually a couple of joints rather than just one).
    • disseminated gonococcal infection syndrome (migratory polyarthalgias, skin lesions, tenosynovitis)
  • very difficult to grow GC from a joint, but other cultures may well be +ve (e.g. pharyngeal or genital)
  • admission for treatment (ceftriaxone IV/IM daily) recommended

References:

  • Rosen’s 8th Chapter 116

[Featured Image: Wikimedia Commons]

Tasty Morsels of EM 045 – Parvovirus B19

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Everyone knows the slapped cheek syndrome that runs in epidemics in kids. Hopefully you’ll be aware of the risk to pregant mothers with this infection.

There are however other complications that you need to know about that just might appear in your ED or in your FCEM

Arthralgia/arthritis

  • keep parvovirus in your differential for someone presenting with an acute poly arthritis, especially if there’s a recent flu like illness in the back ground
  • usually symmetric and in the small joints (something that might make you think rheumatoid but you probably shouldn’t head that direction until symptoms have been present for more than 6 weeks)
  • most will have a rash but in adults don’t expect the classic slapped cheek
  • should resolve within 3 weeks and there shouldn’t be any joint destruction

Transient Aplastic crisis

  • typically someone with some kind of haematologic problems eg sickle or iron def anaemia
  • the scenario you should think of this is when you get the FBC back and there an unexpected anaemia
  • usually it’s only red cells involved. If checked reticulocytes should be low

References:

  • UpToDate
  • Rosen’s 8th Chapter 116

[Featured image CC license, via Wikipedia]

 

Work as an emergency fellow in Ireland

I posted on this last year but the department I work in as a few upcoming vacancies in July so I thought I would update things for those who might want to come work.

MMUH resus

Are you an emigrated Irish doc in training in Oz or NZ and fancy coming home for 6 months as part of your training? Are you a kiwi or Aussie and fancy some time in Europe as part of your training?* Do you simply want to come and work in a different system and advance your practice. Then these might be the jobs for you. Are you an Irish trainee between basic and advanced training? If you’re working in Ireland and fancy a career development opportunity in one of the big Dublin hospitals then read on. 

[* the Mater is accredited for training in Ireland through the (recently Royal) college of emergency medicine which is the specialist college for emergency medicine in the UK and Ireland. From communication with the Australasian College in Emergency Medicine (ACEM) we have been told that any trainee wishing to undertake training overseas and have that time accredited toward their ACEM training can apply to ACEM prior to beginning the post and obtain prior approval to have the training added toward their ACEM training. So as far as we know we are eligible for training by ACEM too]

The Mater Misericordiae University Hospital (The Mater) in north Dublin is one of the main tertiary centres in the country. It has the national spinal injuries centre and all major specialities apart from neurosurgery and as far as I’m aware it’s the only place doing ECMO in the country. The hospital recently (2013) moved to brand new facilities including a new Emergency Dept, theatres and ICU.

The ED encompasses a large ‘acute floor’ model with acute medicine working out of the same department.  There is a 5 bed resus with CT scanning within the resus bay. There are 2 dedicated ED ultrasound machines.

The hospital serves one of the more deprived areas of Dublin with the obvious result that it sees a fascinating range of pathology from stab wounds, pedestrian trauma to complications of alcohol and  intravenous drug use and all the interesting infectious disease complications that come with it. One of the emergency medicine trainees is a lead for an international HIV screening project in the department.

The ED has created several posts at registrar level to attract new staff and facilitate career development. All posts have protected non clinical time to pursue the appropriate sub specialty. Clinical work will be on the registrar rota in the ED.

Link to official job advert [search for mater misericordiae]

Video ad from Dr Tomas Breslin, Consultant in EM, Mater Hospital

Feel free to contact myself [emergencymedicineireland [at] gmail.com] or Tomas Breslin [tbreslin [at] mater.ie] if interested.

Fellow in imaging

  • 20% protected non clinical time
  • 2 machines in ED
  • Weekly USS teaching (led by fellows)
  • Liaison with emergency radiology (fellowship trained)
  • Echo Module
    • 6 months
    • 2 hrs/wk in ICU with echo tech supervised scanning
    • 1hr/wk with ED/CCU patients with echo tech supervised scanning
    • Formal lectures
    • Examination
  • Early Pregnancy Module
    • based in local maternity hospital
    • this years fellows just starting
  • Suitable for (but not limited to)
    • post basic EM training, able to work clinically as registrar/advanced trainee in ED
    • prior to entry to formal higher training scheme, allows clinical development and level 1 USS skills with space to develop CV prior to application to higher training OR
    • post training as a fellowship to acquire higher level ultrasound skills
    • particularly well suited to UK/Australasian/South African trainees as registration recognised

Education fellow

  • University hospital with huge opportunities for educational development
  • Already happening in ED
    • weekly Registrar/consultant teaching (focused on FCEM exams)
    • weekly SHO teaching (focused on basic approaches to EM)
    • monthly radiology/EM/Acute medicine meeting
    • weekly ultrasound teaching
    • monthly joint EM/ICU meeting
    • Regular student placements as elective students throughout year or 4th year students for weekly placement jan-march
    • Online education induction package for SHOs and student placement
  • 30% protected time for non clinical activities to coordinate and develop education in emergency medicine
  • Suitable for (but not limited to)
    •  post basic training in EM,
    • able to work clinically as registrar/advanced trainee in ED

Conflict of interest statement

  • I work in the ED and really quite enjoy it there but no favours, cash or back rubs were exchanged for this post. I am happy to promote (on the same “no favours, cash or back rubs” terms) other interesting/innovative Irish emergency medicine jobs if people see the need.
  • My opinions are of course my own and do not necessarily represent that of the hospital.

Magnesium for Migraine

Migraines are fun to treat. Not so fun for patients but at least we can fix most of them.

It’s always nice to have another tool or two in the armamentarium for treating migraine.

While hardly surprising given this noble element’s history, it turns out magnesium has been studied for migraine before with some equivocal results. This new paper was an interesting read and as I’m prepping for the FCEM critical appraisal exam I may have overthought the stats and methods here. Please let me know if I’m barking up the wrong tree, I’m sure Carley will 😉

The paper:

Comparison of Therapeutic Effects of Magnesium Sulfate vs. Dexamethasone/Metoclopramide on Alleviating Acute Migraine Headache. [pubmed]

METHODS

  • Study type
    • RCT double blind
  • Population
    • ED patients who someone thought had migraine by ICHD criteria
  • randomisation was computer generated
  • Intervention
    • the drugs appear well blinded
    • 10mg metoclopramide/8mg dex v 1g mag
    • allowed rescue meds but don’t say what they were
  • Power calculation
    • This struck me as a bit funny. They don’t state it clearly but it looks like power was based on a primary outcome of a 2cm difference on pain scale at 2 hrs.
    • It’s also not clear if they’ve done the power calculation to compare one drug versus the other or just looking to see if there was a 2cm pain reduction from baseline at 2 hrs. If it was powered simply to show that either drug is effective at 2 hrs then it’s not really a comparative study.  Here’s the quote to see what you think:
      • With power set at 0.9 (b = 0.01) [Note this must be a simple typo: beta should = 0.1 not 0.01] and error level at 0.05 (a = 0.05), we estimated the minimum sample size for the study to be 31 subjects on each arm to detect a 2-cm difference in the pain intensity score (NRS at baseline vs. NRS at 2 h).

RESULTS

  • 70 patients
  • both interventions worked but mag worked quicker, there’s a nice graph to show the effect
  • as for primary outcome pain score at 2 hrs was 0.66 cm v 2.5 cm with a p value of <0.0001. This also smells a bit funny as if the trial was powered to find a difference of 2 cm between the two drugs and the actual difference they found was only 1.84 cm it’s hard to see how that gets them a p value with so many zeroes. However if the trial was powered to show that either drug can reduce headache from baseline then the p value makes sense.

CONCLUSIONS

  • the big issue here is what they were actually testing. from reading the conclusions the authors make it looks like a comparative trial but if it is then the stats look and power calculation don’t smell right.
  • setting aside the complicated machinations of the stats that I may be misinterpreting, it seems from simply looking at the numbers that this seems to have an effect. Whether or not it’s better is up for debate and it may well be the natural course for migraines to get better over time no matter what we do.
  • as always would be nice to see a bigger study in a setting more similar to ours.

 

Some other magnesium headache studies (from the reference list)

  • Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C. A randomized pro- spective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the emergency department. Cephalalgia 2005;25: 199–204.
  • Corbo J, Esses D, Bijur PE, Iannaccone R, Gallagher EJ. Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine head- ache. Ann Emerg Med 2001;38:621–7.

Some #FOAMed

Take home points from an HMIMMS course

Before christmas I finally got another one of the alphabet courses under my belt – The Hospital Major Incident Medical Management & Support course. Or HMIMMS for short.

To be perfectly frank major incidents weren’t exactly on my radar – I like to describe emergency medicine in Ireland as one long protracted major incident so there’s a little bit of incredulity involved in actually planning for some major disaster when we can’t even manage the day to day.

Having done the course I now see why it’s considered as mandatory for training in emergency medicine. Emergency physicians will always be front and central in such scenarios, and the more senior you are the more important the management bits will be. The clinical stuff is easy but making sure your patients and staff get to where they need to be is a whole different story.

The table top exercises are some kind of cross between Monopoly and Settlers of Catan so it allows to unleash your inner geek a bit too.

Below are a few scribbled notes I took during the course and from reading the manual (which of course @EMManchester is an author of… that guy gets everywhere…)

Major incident

  • events that owing to the number, severity, type or location of live casualties require special arrangements to be made by the health services.
  • can also be put as “major incidents occur when the resources available are unable to cope with the workload from the incident”
  • A major incident can remain “uncompensated” when still unable to manage despite mobilisation of additional resources

7 main principles (abbreviated as the fairly unpronounceable CSCATTT)

  1. command
  2. safety
  3. communication
  4. assessment
  5. triage
  6. treatment
  7. transport

Phases of a major incident

  • pre hospital
  • reception
  • definitive care
  • recovery

The Collapsible Heirarchy

  • still not sure if i like the term
  • refers to the system used to delegate staff
  • roles can be coloured red yellow green in order of importance
  • some folk may fill multiple roles until further help arrives
    • for example at 2am the only surgical doctor in the hospital may be the poor surgical SHO who will assume the role of “senior surgeon” (in charge of entire surgical response) until someone more senior arrives and the SHO can go and change his underwear, or perhaps even his career.

Essential clinical roles that need filled ASAP

  • medical coordinator
  • senior EP
  • senior MLSO(lab)
  • senior surgeon
  • senior physician (often overlooked as we assume all major incidents are traumatic when they’re not – they can be toxicological or environmental

Triage

  • the most important thing is that the expectant cases are low down the list. A resuscitative thoracotomy may not be appropriate when your resources are over stretched
  • start with a triage sieve, so simple you don’t need to be clinical to use it. For example if you can walk then you’re immediately a lower priority.
  • a triage sort is a bit more detailed that involves some physiologic variables (GCS, HR, RR) to determine your level of priority (which is essentially which physical space you are assigned to in the ED).

There are some specific Irish documents available online looking at this in the Irish context. Your hospital will of course have it’s own major incident plan. it is no doubt dusty and out of date somewhere…

[Featured Image: Nuclear Explosion – Wikimedia Commons, CC License]