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

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]

Tasty Morsels of EM 044 – Thyrotoxicosis Factitia

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.

This was something I wasn’t even aware existed but worth considering.

Classic symptoms of hyperthyroidism

  • tachycardia
    • usually sinus
    • a fib common too
  • sweating/feeling warm
  • poor sleep
  • weight loss
  • possible fine tremor
  • eye signs (Graves only)

Causes of these symptoms

  • usually Graves disease in the west
  • toxic multinodular goitre in areas of iodine deficiency
  • thyroiditis
  • the odd tumour here and there
  • the odd drug here and there (amiodarone and lithium being the big ones)
  • exogenous thyroid hormone use (rejoicing in the name thyrotoxicosis factitia)

The (very) basic physiology

  • Thyroid Stimulating Hormone (TSH) causes thyroid to produce more thyroid hormones
    • controlled by the axis of evil, hypothalamic-pituitary-thyroid axis
  • The hormones are:
    • T3 (triiodo- thyronine)
    • T4 (thyroxine)
  • Most T3 comes from conversion of T4 to T3 peripherally (liver and muscle mainly)
  • T3 is more biologically active
  • In most hospitals I’ve worked T3 isn’t measured routinely

Thyroid hormones can be taken surreptitiously in a few situations

  • reported outbreaks of hamburger thyrotoxicosis from ground beef from the neck of the animal
  • ingestion of various weight loss products that can contain either T3 or T4
    • note if it’s T3 causing the symptoms then T4 may be normal but the TSH should be suppressed. If your lab doesn’t normally measure T3 then it’s worth thinking about (a very smart biochemist had to explain all this to me)

The differentiating feature is probably the eye signs. Graves is the commonest cause of thyrotoxicosis in the west so if you see someone with classic hyperthyroidism and no eye signs then it’s always worth asking them about various supplements they may be taking.

References:

  • Rosens 8th Chap 128
  • UpToDate: Exogenous hyperthyroidism
    • An outbreak of thyrotoxicosis caused by the consumption of bovine thyroid gland in ground beef. Hedberg CW, N Engl J Med. 1987;316(16):993.

 

 

 

Location based decision making

This is something that I’ve noticed happening to me for as long as I’ve been doing emergency medicine (coming up on 10 years now) – that the physical part of the department that you see the patient in has a significant impact on my decision making process. 

A patient with chest pain arrives in resus, the staffing ratio is much higher here. The expected rate of pathology for all staff working in the area is much higher. Before the doctor sees the patient it is likely that the patient will be on a trolley, on a monitor, often an IV cannula is inserted and lab tests are flying through the chute to the lab before anyone has even further assessed the patient. Often the patient is changed to a gown and an ECG will be done.

A second patient with chest pain arrives and is brought to the minors area. There are no cubicles so they sit in a chair awaiting a doctor’s assessment. No further testing or assessment is done. As there are still no cubicles available to assess the patient the doctor apologetically walks the patient to the psychiatry interview room as it is the only free space in the ED with a door that can close to give the patient even the slightest bit of dignity.

I find when I am the doctor in both those situations I make rather different decisions, or at the very least, I feel inclined to make different decisions even if I ultimately don’t do so. The assumption of course is that if the patient is in the minors area then it’s not possible for the patient to have serious pathology and indeed vice versa – if they’re in resus then it’s not possible for them to have minor pathology.

I suspect everyone working in emergency medicine as noticed this to some degree. Hopefully those who are thorough enough will be able to make appropriate and safe decisions (sometimes involving waiting until a cubicle is free and properly exposing and monitoring the patient) no matter what the environment.

However it is a useful reminder, once again, on how overcrowding in the ED is a threat to safe and effective medical care. Ireland has had its own crisis this week – which of course only means that we got in the papers; the ongoing major incident that is the result of the decision to locate all crowding in the ED has been going on for much longer… While people often view ED attendances as simply punters seen by nurses and doctors, there is rarely reflection on the on the fact that working in an overcrowded environment with the compromises it requires exposes patients to the harm of cognitive biases and poor decision making.

[featured image via wikimedia commons]