With millions upon millions of journal articles being published every year it is impossible to keep up. Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.
Stories are a powerful vehicle for education. Combine a story with some active participation and you have the recipe for some great learning. And so, it’s with great delight, that we bring you Chapter 1 of PEM Adventures. First presented at EuSEM 2018 and then again with some spectacular twists by Dan Lumsden, Paediatric Neurologist extraordinaire, Dani has a particular soft spot for Tomas, a little boy who dreams of being a footballer. Join us on a journey (with an inbuilt time travel machine) in managing Tomas, a little boy with a dream…
Meet Tomas, an 8-year-old boy who dreams of playing professional football. He’s been completely well until an ill-fated shopping trip for some new football boots. At 2 o’clock hours, while trying to persuade his mother that he definitely did need the new Premier League football to add to the collection, he developed sudden onset right-sided facial drooping. His mum bundled him into the car and drove him directly to your ED. You look at your watch: it’s now 3.30 pm.
Your assessment is as follows: Tomas is alert and he seems orientated. He has right sided facial weakness and weakness of both his right arm and leg. He has no obvious sensory changes but is struggling to communicate with you as he has global aphasia.
Suspecting the worse, you have a critical decision to make. But what are you going to do?
Call neurology
You bleep neurology.
And wait…
They don’t answer so you bleep again…
But they still don’t answer…
You bleep a third time…
But they still don’t answer. So you give up and call radiology instead.
Call radiology
You call radiology. And they ask… What imaging do you want?
CT? CT with contrast? CTA?
The radiologist says, “Sure, imaging sounds like a good idea. Let’s do a combination of both a CT brain with CTA to look for blood and clots.”
The CT scanner is available at 16:00.
“But,” she adds, “if you’d like MR imaging, we could do that at 18:00.”
Do you…
Proceed with CT and CTA
Tomas’ CT and CTA shows evidence of an arterial ischaemic stroke with thrombus occluding the middle cerebral artery. There is no intracranial haemorrhage.
It is now 16:15, 2 ¼ hours after the onset of Tomas’ symptoms.
You’re doing great. Close the toggles and move on to the next part of Tomas’ case.
Say, “Actually, I’ll have MR imaging please.”
Tomas has an MRI and MRA.
It shows an arterial ischaemic stroke with thrombus occluding the middle cerebral artery.
It is now 18:45, almost 5 hours after symptom onset – something tells you this is a bit too late.
Luckily for you, the inbuilt time machine whizzes you back to make that last decision again.
This time when you’re told you can have an MR and MRA at 18:00 or CT and CTA now you say… “I’ll have a CT and CTA now please.”
MRI? MRV? MRA?
The radiologist says “Sure, imaging like a good idea. Let’s do a combination of both an MRI plus MRA to check the brain and look for clots.”
You phone MR. They say they can do the MR at 18:00. The CT scanner, however, is free now.
Do you…
Proceed with MR at 18:00?
Tomas has an MRI and MRA. It shows an arterial ischaemic stroke with thrombus occluding the middle cerebral artery. It is now 18:45, almost 5 hours after symptom onset – something tells you this is a bit too late.
Let’s travel back in time…
This time when you’re told you can have an MR and MRA at 18:00 or CT and CTA now you say… “I’ll have a CT and CTA now please.”
Say, no thanks, I’ll have a CT and CTA please.
Tomas has a CT and CTA. It shows evidence of an arterial ischaemic stroke with thrombus occluding the middle cerebral artery. There is no intracranial haemorrhage.
It is now 16:15, 2 ¼ hours after the onset of Tomas’ symptoms.
You’re doing great. Close the toggles and move on to the next part of Tomas’ case.
With a little luck, Tomas has now had neuroimaging and you know he’s had an arterial ischaemic stroke with thrombus occluding the middle cerebral artery without intracranial haemorrhage.
So, what now? You haven’t managed to get hold of a neurologist for love nor money. So do you…
Admit for supportive care
Tomas has supportive care.
Despite physio, OT and lots of assistance at the best neuro-rehabilitation centre, Tomas has a persistent hemiparesis.
You spend your life wishing you’d treated his stroke differently.
So let’s try that choice again.
Give Tomas aspirin
You prescribe 5mg/kg aspirin.
Tomas has repeat imaging with an MRI and MRA 24 hours later. His clot has not increased in size but the original clot remains in the middle cerebral artery.
Tomas has a persistent hemiparesis.
He becomes a demon-swimmer and wins Gold in the 2028 Paralympics
However, you spend your life wishing you’d treated his stroke differently.
Why don’t you try that choice again.
Anticoagulate with heparin
You prescribe heparin.
24 hours later Tomas deteriorates, dropping his GCS to 6
Repeat neuroimaging shows a large haemorrhage in the infarcted territory with significant pressure effect.
Let’s go back in time and try that choice again.
Thrombolyse
You decide to thrombolyse. Tomas will need to go to PICU after thrombolysis but there isn’t a PICU at your hospital.
Do you…
Transfer to the regional centre and thrombolyse there
You opt for thrombolysis at the regional centre but will you…
Transfer yourself
You work fast to mobilise your anaesthetist, ED nurse and emergency kit as quickly as possible.
Tomas arrives at the regional centre at 19:15, 5 ¼ hours after the onset of his symptoms.
It is too late to thrombolyse.
Let’s hop in the time travel machine and go back in time to decide whether to transfer for thrombolysis or thrombolyse in your ED (Hint: you may want to thrombolyse in your own ED as the clock is ticking…)
Ask the retrieval team to transfer
The retrieval team are mobilised. They collect Tomas from your ED and deliver him safely to the regional centre at 19:15, 5 ¼ hours after the onset of Tomas’ symptoms.
But it’s now too late to thrombolyse.
Let’s hop in the time travel machine and go back in time to decide whether to transfer for thrombolysis or thrombolyse in your ED (Hint: you may want to thrombolyse in your own ED as the clock is ticking…)
Thrombolyse in your ED and then transfer
“Time is critical,” you think to yourself, and tell the team you’re going to thrombolyse in resus.
Tomas is thrombolysed with tissue plasminogen activator (tPA for short) at 18:00, 4 hours after onset of symptoms. His symptoms start to improve.
After intensive neuro-rehab he has no residual neurological deficit.
He grows up to become a professional football player for Bayern Munich, scoring a hat-trick to win the 2028 UEFA champion’s league.
Congratulations! You successfully treated a stroke in childhood. Now close the toggles and read on…
Organise an angiographic thrombectomy
Although you opt for angiographic thrombectomy, the interventional neuroradiologist is on study leave and no-one is able to cover.
You suspect they are actually scared of children.
Either way Tomas can’t have the clot removed. You’re going to have to choose again.
Refer to neurosurgeons for a hermicraniotomy
You phone the neurosurgeons and ask them to do a hemicraniectomy.
They ask you to go through all his neurology and review his imaging.
They say “Sorry, but his PedNIHSS isn’t high enough for us to take to theatre.”
You think, “PedNIHSS?” and make a mental note to look it up later.
Let’s try that choice again.
After your shift you do a quick google search to look at the evidence around using tPA in children and you stumble across this paper:
Rivkin’s team were part of a huge multi-state stroke research team in North America. They designed the incredibly well thought out and well put together TIPS (Thrombolysis in Paediatric Stroke) study, to look at (A) safety of and (B) dose of tissue plasminogen activator (tPA) in children presenting with and arterial ischaemic stroke (AIS). They set out to recruit children aged 2 – 17 with acute AIS and PedNIHSS score between 4 – 24 to receive tPA if initiated within 4.5 hours of symptom onset. Centres were given protocols to manage complications such as intracranial haemorrhage, systemic bleeding, hypotension or angioedema.
Sounds good, right?
Well, in principle, yes. The study opened in April 2012 but closed only 20 months later in December 2013 because only 1 child had been enrolled and they hadn’t actually been treated due to complications following extubation prior to tPA administration.
93 children had been screened with 43 having confirmed AIS and the other 50 having a stroke mimic such as migraine, seizure or tumour etc.
Of the 43 children with AIS about half had medical contraindications to tPA (including moyamoya disease & anticoagulation treatment); 10 were outside the treatment window (including 1 who missed the treatment window by 15 minutes due to delay at scanner); some had a PedNIHSS that was too low ; 1 had a PedNIHSS that was too high; and a couple didn’t have arterial occlusion on imaging.
But it wasn’t a total disaster. Preparing for TIPS also led to the development of Paediatric Stroke Networks in North America. And designing the TIPS study led to consensus guidelines on the management of stroke in children.
These consensus guidelines derived from the TIPS study design have been extrapolated to the 2017 RCPCH Stroke in Childhood guideline, based on expert opinion and the best available evidence. As well as the full guideline, there’s a simple, easy to follow pathway poster that can be grabbed for quick reference whenever a child presents with potential stroke symptoms.
The poster gives a list of potential stroke presentations, from an unexplained persistent drop in GCS, through acute focal neurology (even if resolved), focal seizures, headaches, ataxia, dizziness, speech disturbance and a prompt to consider stroke in children with sickle cell disease.
It includes a simple, easy to follow, Paediatric National Institute of Health Stroke Scale (that PedNIHSS we’ve talked about) a bit like a Glasgow Coma Scale but specific for paediatric stroke. The PedNIHSS makes up a really important part of the neurological assessment, a way of scoring the severity of the stroke. It is vitally important that the PedNIHSS is calculated because if the score is very low, with a very minimal deficit at the outset, the risk of thrombolysis outweighs the potential benefit. And if the PedNIHSS score is very high, it’s likely that the child has a very large area of brain damage, with a high risk of haemorrhage into that infarcted territory, again making the risk : benefit ratio too risky. The child’s PedNIHSS score guides your subsequent management.
The pathway lists investigations (which must include coagulation profile and group and save, because of that risk of bleeding), monitoring and neuroimaging. Timing of imaging is key. The guideline states that children should be scanned within 1 hour of presentation to the ED. Pragmatically, this is usually CT with CTA (the angiography component to look at the arteries), because organising an MRI with MRA takes longer. But, if you’re in an institution with great access to MR and you can get your imaging within an hour of presentation then it’s definitely worth a discussion with the radiologist.
If a child has a confirmed AIS, what do we do? The guideline offers two either / or treatments: EITHER aspirin 5mg/kg within an hour, as long as there is no parenchymal haemorrhage OR thrombolysis. The guideline suggests that thrombolysis may be considered in children aged 2-8 and could be considered in children over 8 (some careful wording there because extrapolating evidence from adult studies to an 8 year old is easier than to a 2 year old) provided the PedNIHSS is between 4 and 24 and tPA can be administered within 4.5 hours of symptom onset. There must be either MRA evidence of thrombus or normal or only minimally ischaemic changes on CTA (no huge areas of ischaemia, because the risk of bleeding into it is just too high), with or without evidence of thrombus. And as the biggest risk of giving tPA is haemorrhage, there must be no contraindications, such as abnormal clotting, an underlying bleeding disorder, malignancy, hypertension or moyamoya disease.
It’s really important to note that the treatment for AIS is not the same as for a child with a haemorrhagic stroke (these children need urgent discussion with a neurosurgeon for consideration of evacuation) or a child with an ischaemic stroke secondary to sickle cell disease (pick up the phone, call a haematologist and organise an exchange transfusion). Although not included on the poster, the guideline summary and full guideline give indications for surgical and endovascular interventions in stroke, as well as those nuggets for managing stroke in a child with sickle cell disease or haemorrhagic stroke.
And what about thrombectomy? This is a very active area of interest. In the world of adult AIS there has been a big move towards primary clot removal by thrombectomy rather than clot busting with thrombolysis. In the world of paediatric stroke, although there are some published case series and case reports, we don’t have a clear evidence base or national guidance. Yet.
So, what is the take-home from Tomas’ case? Although stroke is rare in children, it does occur. Thrombolysis is a potential management option given the right conditions, as long as it’s given within the 4.5-hour window. So, next time you see a child with stroke-like symptoms, send bloods early, get early neuroimaging with angio, and pull out the RCPCH Stroke in Childhood poster.
With special thanks to Dr Dan Lumsden, Paediatric Neurologist at the Evelina London Children’s Hospital, who inspired the creation of Tomas’ case and presented him so fabulously at the Royal Society of Medicine. Thank you, Dan.
Sam, a 12-year-old boy, presents to your department after a soccer blitz. He was tackled, heard a pop, and now can’t weight bear on his right knee.
As popularity and intensity of children’s sports increases there are increased demands placed on children and adolescents. This has resulted in an increased presentation of children like Sam. They can present with knee pain that is traumatic or atraumatic, acute or chronic. Paediatric patients are particularly vulnerable to overuse injuries involving the physes and apophyses due to their inherent weakness (see post, hyperlink article on fractures around knee).
Along with these there has also been an increase in soft tissue injuries. These are seen more commonly in older children/adolescents as their bones become stronger and are less likely to fracture with age.
Important points to note on the history include:
Recalling the anatomy of the knee makes evaluating the site of pain easier. The following make up the knee and all can be can be injured/inflamed and cause pain.
Examination in the acute setting is often difficult and may be limited. This is due to swelling, pain and anxiety. Try your best to be as detailed as possible but ensure you note any red flags on examination. These are:
After a thorough history and examination you discover he was tackled and the other player’s foot landed on the lateral aspect of his knee. On examination you find a swelling on medial aspect of the knee and laxity of the medial collateral ligament when valgus stress is placed on the right knee. You clinically diagnose a medial collateral ligament injury. He is placed in a brace and referred to orthopaedic clinic.
Injured ligaments are considered “sprains” and are graded on a severity scale.
Ligament specific examinations:
A short while later one of Sam’s team mates, Patrick, presents to ED. He was also playing in the soccer blitz. He got sudden knee pain when turning and his knee is now locked. Following assessment you suspect a meniscal injury.
Meniscal injuries can be traumatic or atraumatic. Suspect if the knee is locked, there was a twisting mechanism, a tearing sensation, or an effusion.
Specific examinations include:
Treatment includes physiotherapy to compensate for the tear but surgical management may ultimately be required. Follow up with orthopaedics is required.
Patrick’s sister was also brought for review. She is 15 years old and has been having intermittent knee pain for the last few months but it gets much worse after she plays sports. She also says it really hurt her after the cinema yesterday. You suspect patellofemoral pain syndrome.
The pain is frequently described as anterior but is often poorly localised. It may feel like it’s “under” or “around” the patella. Pain is classically exacerbated by prolonged periods of sitting, use of stairs and squatting (theatre sign). Pain may be present for several weeks, exacerbated by activity and relieved after periods of rest. Frequently there is a deterioration in sports performance or inability to participate prompts patients to seek medical review.
Clinical examination should look for gait abnormalities, increased lumbar lordosis, and any asymmetry in hips or lower extremity. It is not uncommon to have reduced flexibility in the hamstrings or quadriceps.
Clarkes sign – positive in PFPS. Patient supine, knee extended. Grab the superior pole to the patella with thumb and index finger and have the patient activate the quadriceps while you inhibit the patellar movement. This causes grinding of the articular surface between patella and femur. Pain is indicative of PFPS.
Investigations are not routinely required. However, knee radiographs may assist in ruling out other conditions such as osteochondritis dissecans of the knee/patella and stress fractures of the patella. Radiographic imaging in PFPS is not diagnostic. It is necessary to combine any findings with your clinical examination.
Management of this is conservative as it is a self-resolving condition. It typically resolves over weeks to months but has been known to take up to two years for complete resolution of symptoms. Management involves reduction in activity (complete cessation usually not required), ice, rest, anti-inflammatory for pain control (short term use), avoidance of aggravating exercises (e.g. squatting) and some find relief with taping/knee-braces. Exercises that strengthen and increase flexibility of the quadriceps, hamstrings, soleus and gastrocnemius muscles are also recommended.
A thorough history and examination can greatly assist in reaching the diagnosis. A correct diagnosis helps to properly counsel patients and appropriately manage their expectations. Without proper treatment, knee injuries can lead to chronic knee problems, early onset arthritis, injury to surrounding tissues, and prolonged healing times. Missed injuries can also cause recurrent cartilage damage, instability in the knee, and unnecessary time away from physical activity. It is our duty to diagnose these injuries in a timely manner and provide appropriate advice, support and follow up.
Below is a useful table outlining the causes of intrinsic knee pain, separated by site of pain on examination (table 1).
Finlayson C. Knee injuries in the young athlete. Pediatr Ann. 2014;
Brooke Pengel K. Common overuse injuries in the young athlete. Pediatr Ann. 2014;
Beck NA, Patel NM, Ganley TJ. The pediatric knee: Current concepts in sports medicine. J Pediatr Orthop Part B. 2014. doi:10.1097/BPB.0b013e3283655c94.
Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain. Part II Am Physician. 2003.
PEM Playbook Knee Pain podcast https://pemplaybook.org/podcast/knee-pain/
Throughout my career, I’ve always had a keen interest in trauma. As I prepare to depart to take up a trauma fellowship at the Alfred hospital in Melbourne, I was interviewed for the case report podcast and asked for some of my ‘tips and tricks’ of the trauma care trade. When I started to prepare for that talk and now this blog post, I thought, what would I like to have known when I started off receiving major trauma patients? What advice would I give to my more junior self?
“Professionals prepare properly”. That phrase that I first heard from friend/colleague/mentor Dr Cian McDermott (@cianmcdermott) is still ringing in my ears. We need to prepare now for that patient that we might meet on shift later on today, perhaps tomorrow or maybe even years into the future. If preparation is key, then I feel that the ‘zero-point survey’ from Cliff Reid et al. is a great place to start. It represents somewhat of a change to the traditional teaching that we are all familiar with such as ATLS (Advanced Trauma Life Support) in that it asks you to prepare to receive the patient before the point of first patient contact. It asks you to ready yourself, your team, your environment, and your system. So here are some of my hopefully helpful hints, framed around the survey.
Is it just me or does a major trauma pre-alert bring about the flight before the fight response? How often does a team member come to you and their first contribution is… do I have time to run quickly to the toilet? They do. You do. Always. Manage your own stress.
When I am the Trauma Team Lead (TTL) preparing to receive a patient, I often walk the long way around to the resus room. This may seem strange when time is of the essence, but it affords me that thirty seconds of headspace for a quick personal pep/prep-talk. It allows me to clear my mind, focus on the task at hand, formulate a plan, rationalise my ‘fight-flight’ response that will allow me to optimise my ability and to meet the patient on the correct side of the Yerkes-Dobson curve. When a patient is at their worst, they demand your best!
As trainees, at the end of each year, we are asked to fill out an end of year assessment for ourselves and our training sites. The questions are straightforward until, question four. List your weaknesses.
This can sometimes be hard, not because we are perfect (far from it), but because we often either do not acknowledge our weaknesses or indeed somewhat suppress them. We need to look critically at ourselves, to find our weaknesses and then, to address them. For me, as a junior trainee, I felt that I needed to improve my airway skills, so I attended the TEAM course. I wanted to enhance my critical care management, so I attended the ED-Critical care course in Ede, Netherlands with Cliff Reid. Are you confident with the advanced resuscitation skills that are required in trauma? Could you perform a lateral canthotomy, pericardiocentesis or thoracotomy? If not, find a course (shameless plug www.resuscitate.ie)!
Emergency Medicine is far better than General Surgery (cue onslaught)! To qualify this, I started life as a basic surgical trainee before transitioning to Emergency Medicine and for me, my work-life balance instantly became better! There were many reasons for this.
I am passionate about Trauma Teams (TTs) as they have been shown to optimise patient care by reducing time to diagnostics and interventions. In Ireland, there are currently no accepted TT configuration or activation criteria for such a team. This presents a massive challenge in terms of data capture with only 8% of major trauma patients documented as being met by a trauma team on arrival. I have recently written a position paper for IAEM (Irish Association for Emergency Medicine) and the Emergency Medicine Programme (EMP) on TTs that can be used for collaborative engagement with the National Trauma Office as well as to engage with the key stakeholders including Surgery, Critical Care, Trauma & Orthopaedic Surgery and nursing amongst others to aid the development and roll-out of TTs for Ireland so, watch this space!
Back to the survey. Prepare the team. As the TTL; assess the pre-alert (remembering Mansoor Khan’s wise words that in major trauma, “the word stable only refers to the place where a horse lives”), activate the appropriate team, allocate appropriate roles, and anticipate what this resus may entail.
What is the best-case scenario? What is the worst-case scenario? Create a shared mental model with the team. If a thoracotomy is required then having anticipated this prior to the patient’s arrival might alleviate some of the fear factor. If a team member is not comfortable witnessing such a resuscitation, then it allows them to excuse themselves at an earlier stage.
Noise suggests chaos. It may indeed be the pen perfect resuscitation, but if people have to raise their voice and even shout to be heard, this can often be disruptive.
Is the environment ready? Is there sufficient space to receive the trauma? If anticipating a Code Red (massive transfusion), could two resus bays be made available? Is there a dedicated trauma bay? If not, can one be established?
Check and re-check equipment. Are there blood products in the fridge? Have the rapid infusers been primed and readied? Is there any additional equipment that is likely to be required such as good trauma shears (preferably ones with no plaster of Paris on it!), pelvic binder, good haemostats (not Kaltostat), bite blocks etc. If the equipment that you require is not available, where can you get it from? Can you improvise? Two quick tips; CAT (Combat Application Tourniquet) MIA? Use a manual blood pressure cuff. No McKesson bite blocks for your Le fort II/III? No problem! Use a few tongue depressors taped together (Thanks to Jason van der Velde).
If the equipment is there, then use it. When it comes to POCUS, you may not be using E-FAST, but, in a major trauma patient with complex facial fractures, marking the CTM (cricothyroid membrane) ultrasonographically informs the team that surgical cricothyroidotomy is a potential. Pre-empting the requirement for life, limb and sight-saving procedures and discussing them out loud, as a group in advance will go a long way to help avoid decision paralysis.
We can start today by ensuring that our own house is in order. How do we do this? Teach. Train. Simulate. MDT simulation in your resus room allows new processes to be vetted and existing systems tested. Logistics are far more difficult to test in simulation labs. Practice where we preach. Can processes be streamlined? Can default trauma identifications be used? Does the trauma call generate the same response as your STEMI or FAST call? Out-of-hours are trauma calls consultant-led? If not, can telemedicine be used for offsite support?
Are there checklists out there that will allow trauma care delivery in a safer manner? Trauma proformas allow accurate and efficient documentation and also serve to prompt the delivery of time-critical actions.
Multidisciplinary teaching is key. Having a regular trauma forum to discuss the major trauma cases that have attended is crucial. Too often the only forum that these cases are openly discussed is in some Morbidity and Mortality meeting when there has been a bad, or at least unexpected outcome? Do we discuss the ‘good’ cases? Do we hot and cold debrief? Have we Schwartz rounds in our institution?
Nobody will forget 2020 in a hurry. COVID-19 has had a profound impact on each of us. Has it all been bad? I suggest not. Staff numbers have increased (perhaps not as good as they were in May, but certainly an improvement). Emergency Departments have increased in size. Equipment that was on an exceptionally long wish list has suddenly appeared. With this newfound political resource and energy, healthcare has by-in-large, improved (or maybe it is just less bad). With this in mind, trauma care in Ireland is set to undergo reconfiguration with the development of an inclusive System and based on similar international systems, destined to save lives. The political standstill that marred healthcare might be changing. Trauma Care delivery is changing. The Southern and Central trauma leads for Ireland have recently been appointed. With very tightly crossed fingers and a few more grey hairs for the Clinical Lead for Trauma Mr Keith Synnott, a trauma system for Ireland seems to be on the horizon.
Lastly, the handover from your pre-hospital colleagues.
Sometimes in my career, I have felt like the proverbial rabbit in headlights, nodding in seeming agreement with my paramedic colleague but occasionally with little information being retained. Nowadays, I try to summarise the handover in a one-sentence synopsis. This helps me to focus and hopefully the team to do likewise. Always ask for silence and sterility for handover. It only takes 30 seconds and may save much more than this if there is a missed communication piece.
1. Reid C, Peter Brindley P, Hicks C, Carley S, Richmond C, Lauria M, and Weingart S. Zero pointsurvey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med;Sept (5(3)):
Ethics is based in philosophy – the critical evaluation of arguments and assumptions – and therefore is the activity of philosophical reflection about norms and values; right and wrong; good and bad; what ought and ought not to be done. Bluffer’s Guide tip: ethics is Greek and moral is Latin. Talking about ethics and morals is like referring to renal kidneys or cardiac hearts.
Two main theories guide ethical behaviour. The most commonly espoused is that of deontology: a principles – or rules-based approach. This has nothing to do with gods (Latin “deus”). It is from the Greek “deon” for duty. Immanuel Kant (1724-1804)not-a-recent-reference defined the Categorical Imperative, a supreme over-riding principle that is never context-dependent, which rules humans absolutely, and which is felt even when defied. It’s like Pinocchio’s Jiminy Cricket. For Kant, the foundation of morality was duty. Acts should be considered good or bad of their own right, regardless of the outcome.
The Beauchamp and Childress schema of respect for autonomy, beneficence, non-maleficence and justice is often adopted. Patients should not smoke (no-one should): it’s hazardous to their health and 50% of smokers will die from a smoking-related illnessinsert-reference-of-your-choice. (This includes the fictitious lady who smoked only 19 a day.) Beneficence requires that we act in patients’ best interests and stop them smoking: confiscating cigarettes and frisking visitors for contraband. At the same time, non-maleficence requires us to prevent the effects of withdrawal that we enforce. If patients refuse to use them, we might have to sneak nicotine patches in under the dressings. Justice requires that we treat all patients equally, not spending too much time stopping the smoking because obese patients need to get on the treadmills and time must be allocated to preventing cake-smuggling. Then respect for autonomy requires that patients decide for themselves whether or not to smoke (or eat too much). There’s the rub.Hamlet, nd.
Rules-based approaches are difficult because the rules or principles conflict. Increasingly more conditions (formally known as “ifs and buts”) have to be introduced to make it work. Ifs and buts bring with judgements based on circumstances, so the rules are no longer universal and rigid. Judging what action to take based on guidance (rules that have to be interpreted) and on circumstances is more often known as a consequentialist stance. Discworld fans might recognise this as Commander Vimes’ “dealing with what is in front of you” approach:try “Night Watch” something that will be familiar to all senior clinicians.
An alternative, also not without its critics, justifies actions by expected outcomes. Jeremy Bentham (1748-1832) and John Stuart Mill (1806-1873) were the classic sources of consequentialist or utilitarian theory: that to act morally, we should try to bring about the best consequences. Sometimes, telling lies is right (“Is this spot really noticeable?”), and sometimes, judgement is needed to decide between opposing actions. In health care, possible outcomes are often not clear-cut. Complexity and differing viewpoints make judgements difficult.
Ethical decision-making in research is just as difficult. When to stop a trial because of side effects or because the results are obviously fabulous, whether we can deceive participants for the greater good, and how informed participants need to be can all be problematic. The opt-out article is a discussion of a decision made about informing potential participants and ensuring that they have given valid consent for data to be collected in a research study in paediatric urgent care departments.
Since the bureaucracy never retreats, the content of participant information sheets (PIS) continues to grow. Required items are added, but nothing is ever removed. A 20-page PIS is perfectly normal for a drug trial. Four pages will often be required even for an innocuous survey. GDPR regulations have added one or two pages of the densest and opaque text for those of standard (ie: low) reading age. You don’t read two pages of small print before signing a new mobile phone contract.No-you-don’t! There is evidence that participants don’t read PIS, either, so they are not informed before signing up. There is something odd, too, about requiring the person who is to be protected to sign the researcher’s consent form. The participant’s signature actually protects the researcher by evidencing that consent was sought.
In the study, we adopted opt-out consent in which brief information (one side of A4 in large print and low reading age) was provided, and parents or young people would sign only to indicate a refusal to participate. (This last sentence has a Gunning-Fog readability index of 21.5. Anything above 12 is hard for most people to read!)Years of experience in research with young people has taught us that they will not read more than a paragraph before making a decision, and they will decide immediately, refusing a cooling-off period.
Since that study, incorporation of GDPR into English law has led (in good faith and with appropriate professional concern) to the banning of opt-out consent in NHS research by the Health Research Authority and therefore by the National Institute for Health Research, applying the rule that “active consent” is compulsory. We argue that this is based on the false assumption that opt-out consent implies a lack of information and lack of a decision by participants. The brief information that we supplied had a better chance of being read than a standard PIS, so participants may have been better informed than usual. Parents made a decision for their child’s clinical data to be included and did so by not completing the contact details on the reverse of the form.
Applying a blanket rule like this can damage recruitment to very large studies, may lead to participation without effective information, and places a greater burden of time on participants which is not commensurate with the risks of participation. The law must be obeyed, but what if the law has been misinterpreted? What if the rule brings about worse outcomes? See what you think.
Take a break?
Andrew Tagg. Take a break?, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29431
We spend a large proportion of our lives at work so it is important that we pay attention to our own wellbeing. A casual stroll through Twitter may reveal any number of wellbeing initiatives – from early morning yoga classes, through communal choirs, to meditation mornings. Whilst, subjectively, many of these appear to work, there is clearly a need for a better measure of wellbeing. Enter the NFR.
What is the NFR?
The Need For Recovery scale measures that subjective feeling of the need to take a break and recuperate from the emotional and physical demands of a day at work.
Originally derived from a sample of 68775 shift workers in the Netherlands, it is comprised of eleven dichotomous Yes/No questions.
In the emergency department, there are a number of extrinsic factors that might impact on our Need For Recovery. These include departmental crowding, lack of resources, and ambulances queuing out of the door. The assumption is that the daily accumulation of such tiring shifts, without a restorative break, can impact on our long-term health and increased occupational stress.
In order to look at how we are doing now, it might be worth taking a snapshot of the adult and paediatric emergency department workforce. PERUKI and TERN combined their might to do just this.
Cottey L, Roberts T, Graham B Trainee Emergency Research Network (TERN) and Paediatric Emergency Research in the UK and Ireland (PERUKI), et al. Need for recovery amongst emergency physicians in the UK and Ireland: a cross-sectional surveyBMJ Open 2020;10:e041485. doi: 10.1136/bmjopen-2020-041485
Population
This study was coordinated through the Trainee Emergency Research Networks (TERN) of UK and of Ireland and Paediatric Emergency Research in UK and Ireland (PERUKI).
A total of 4247 emergency physicians* from 112 emergency departments completed the survey.
For the purposes of this study an emergency physician was defined as any doctor working within the ED, be they seasoned veterans or post-graduate year one doctors completing their six-month term in emergency medicine.
Exposure
Participants were invited to take part in an online version of the Need For Recovery instrument. Although developed for industry it has been piloted in Emergency Department staff. Graham et al. (2020) trialed the survey in a single ED and achieved an 80.3% response rate (168/209). These subjects had to complete the 11 point NFR survey as well as an additional 32 questions. This larger survey upped the ante and added 44 items to the NFR. The quality of the web-based survey was maximized using the CHERRIES checklist.
Snapshot data was collected over a six-week period from 3rd June 2019, long before anybody had even heard of SARS-CoV-2.
Outcomes
Before we look at the Need For Recovery it is interesting to look at the demographic data.
3445 (83.5%) survey respondents worked full time. 609 (14.7%) worked less than or equal to 80% full time equivalents.
2886 (70.3%) worked more than one in four weekends with a shocking 1479 (36%) working every other weekend!
36.2% worked for, at most, four consecutive days, with the majority working between five and seven days in a row. 13.5% (554) had been rostered on for eight days straight.
Emergency physicians score higher than paediatricians, miners, paramedics, everyday folk, nurses, merchant sailors and truck drivers
The median NFR score (remember you want it to be as low as possible) was 70.0 (with 95% confidence intervals ranging between 62.0 and 78.0). It appeared to be higher in the more junior cohort – those that had been in the department for less than a year. This group scored an average of 72.7 with an upper limit of 90.9. Those who had spent more time in the job seemed better at recovery with a median NFR of 63.6. Those lucky individuals that had made a career of emergency medicine and had spent over ten years in post had the lowest score of all, 54.5.
As one might expect, higher scores were associated with a full-time work commitment, a burdensome weekend roster, and a higher number of consecutive days worked.
Lower scores were found in consultants and those that worked less than full time. The ability to access study leave and annual leave was also associated with lower scores. Luckily for those of us who have pursued a career in paediatric emergency medicine, this appeared to be associated with a lower NFR score too.
The authors conclude that there are three modifiable risk factors related to a higher NFR – access to annual leave, to study leave, and the proportion of out of hours work. Non-modifiable factors included things like male gender, seniority, generally good physical health, and working in a Paeds ED.
Risk of bias
So far we have reported the facts, as presented but let’s get a little nerdy, as Ken Milne would say, and look at the paper using Burns and Kho (2015) assessment guide for survey reports.
Was a clear research question posed?
Yes – the researchers wanted to look at Need For Recovery scores in a cohort of doctors working in emergency departments throughout the United Kingdom and Ireland.
Was the target population defined?
Yes but… – the target population was defined as any registered doctor who had a fixed contract position (i.e. not a locum) in an emergency department in the UK and Ireland.
There are 183 Type 1 Emergency Departments in England alone. These are consultant-led, 24 hours a day, 7 days a week, 365 days a year services. The authors asserted that they wanted to have over 50% of their respondents from Type 1 centres but this data is not clear in the data presented. Are the majority of respondents from centres that do not have good consultant support?
According to 2018 data, 26% of advertised UK EM consultant places are unfilled. I would be interested to know if individual departmental data could be pulled out and benchmarked against the national average.
Was a systematic approach used to develop the questionnaire?
Yes – the technique was clearly outlined in the methods.
Was the questionnaire tested?
Yes – the questionnaire developed was very similar to that used by Graham et al. The only key difference being around some of the ancillary questions, rather than those analysed in this paper
Were they administered in such a way that response and non-response bias was limited?
Yes – it was distributed in an appropriate way.
Was the response rate reported?
No – though all principal investigators should be applauded for the large number of surveys completed, it is not clear what the denominator is. How many emergency physicians, as defined by the study group) were working during the six week period? Were those doctors who did not even attempt to complete the survey just too exhausted to do so?
Each site PI did provide an best-guess estimate of the number of potential respondents (accounting for sick leave, sabbaticals, annual leave etc.). This number was then used as the departmental denominator, with each site aiming for a 70% response rate. The actual response rate is not mentioned in the paper.
Were the results clearly and transparently reported?
Sort of – there were actually 5107 unique visits to the survey site but only 4247 eligible for analysis. The NFR scores were then calculated as long as a minimum of 8 of the 11 questions were answered. The authors do not mention how they handled the missing data. If only 8/11 answers were provided, how would the addition of 3 further data points affect the results?
The demographic data was clearly reported, barring a few items, as described above, and the rest of the results were presented neatly.
Although I agree with the majority of the authors conclusions I am not so sure I would agree with the assertion that NFR score is unrelated to hours worked. It would seem from the data provided in table 2. those working less than full-time had a lower score.
Where to from here?
The ability to bounce back after a hard day at work is a marker of our general wellbeing. Whilst not everyone can swap over to working in PEM, these data from Cottey et al. would suggest that there are modifiable factors that would improve one’s ability to recover. Interestingly, none of these are within the junior doctors’ locus of control – access to study or annual leave, and better rostering. They are fully in the hands of others. This lack of autonomy can also lead to a lack of motivation.
The term, Need for Recovery, suggests that the onus is on the individual as if they were an elite athlete resting between races. It is not. It is the system that needs to change.
The authors note, in their limitations, that this is just a data snapshot, taken at one moment in time. There is little, in the medical sphere, to benchmark this data against. A similar survey could be carried out, in a different setting, in different geography or at a different time. Are these ratings typical of all areas of the hospital in the NHS or is it just the NHS? Do different craft groups score as highly? Are Need for Recovery scores as high in Australia and New Zealand (Editors note: I’ll work on that one) or are they a product of just working in the ED, regardless of the temperature outside? Are these scores a product of the time? The survey was carried out in the Northern hemisphere summer of 2019. What would those scores be like now, in a COVID ravaged world?
One more thing
There is one non-modifiable risk factor that we have not discussed – gender. Male and female respondents were equal in number but men had a much lower NFR than women – 65.6% (CI 60.8 – 66.5) vs 72.7% (70.5 – 75). But, women are much more likely to be the primary caregiver, you might argue. And you would be right, but even if this is taken into account, women seem to have a higher need for recovery. This seems to hold true in other studies that have looked at gender differences and fatigue.
References:
Burns KE, Kho ME. How to assess a survey report: a guide for readers and peer reviewers. Cmaj. 2015 Apr 7;187(6):E198-205.
Eysenbach, G., 2004. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). Journal of medical Internet research, 6(3), p.e34.
Graham B, Cottey L, Smith JE, et al Measuring ‘Need for Recovery’ as an indicator of staff well-being in the emergency department: a survey study. Emerg Med J Published Online First: 2020. doi: 10.1136/emermed-2019-208797
Van Veldhoven, M.J.P.M. and Broersen, S., 2003. Measurement quality and validity of the “need for recovery scale”. Occupational and environmental medicine, 60(suppl 1), pp.i3-i9.
Winwood, P.C., Winefield, A.H. and Lushington, K., 2006. Work‐related fatigue and recovery: the contribution of age, domestic responsibilities and shiftwork. Journal of Advanced Nursing, 56(4), pp.438-449.
Wood, M., 2005. Bootstrapped confidence intervals as an approach to statistical inference. Organizational Research Methods, 8(4), pp.454-470.