RCEM Belfast 2019 Day 2 post Lunch session

Roof of Revolucion de Cuba restaurant in Belfast. excellent food and brilliant atmosphere.

Stella Smith(Manchester) started the afternoon session with a recount of experiences during the Manchester bomb an year back. It was quite personal for me having been at work on that night at Salford Royal Hospital. I still remember the first patient we took to the CT scanner and the radiographer asking us to check if there is some metal object behind the patient's neck after the initial scanogram. Soon we realised the metal object was a bolt lodged in the cervical spinal cord of this lady. I still get an uncomfortable feeling deep in the heart when I think about that day. The key learning points from the talk were the need for dedicated trauma surgical training for surgeons, improving communication at all levels and the need for dedicated training at all levels. Unfortunately we live in a dangerous time as reminded by the bombs last week in Sri Lanka.

Peter Hulme(Manchester) gave an account of his personal experiences dealing with injured children after the Manchester bomb. It was a well balanced beautiful account of the various simple yet practical difficulties a paediatric emergency physician encounters when an incident of this sort happens. 

Paul Russel(Salisbury) gave an excellent talk summarising various CBRN events around the world including the Novichok in Salisbury. I learnt that a Ram gene meter is used to monitor radiation. There was a brief mention of Bhopal gas tragedy which even today stands as the worst CBRN incident ever. The company responsible for the disaster conveniently avoided penalties by quietly closing down operations and selling the company to another company. He then went through the other incidents world wide from Sarin gas in Tokyo to Polonium in London. As emergency physicians we always are at risk of being the first to encounter a CBRN event. He rightly pointed out that the most dangerous agent will be the innocuous one with delayed onset of symptoms. I do not think there is enough regular training or education on this important aspect of emergency medicine.

Phil 'O' Connor(Belfast) gave a talk on his top 5 critical care papers. Use of high flow oxygen was the first paper and soon we should be seeing this used more in adult emergency medicine. Preoxygentation was the next topic followed by comparison of stylet and bougie for intubation. Then it was about generation of oxygen free radicals due to therapeutic use of oxygen. I do not think there is should be any department/hospital which should use oxygen without a clear prescription from the clinician as to its use.

Rob McSweeney(Belfast) continued where his colleague left off. This was a rapid fire round of critical care updates and he went through a trial every 30 seconds and it was difficult to keep up with the pace at which he was going. He went through the following- POLAR trial for prehospital cooling in traumatic brain injury, RESCUEicp for decompressive craniectomy followed by 20 other trials. I was lost after the first three and was glad that the day was over because my mind was already thinking about which pub and what drink to have that evening.

That was the end of day 2. Going to a conference is a bit like sitting in a classroom all day. I have not done that for a while and struggled to sit down for such prolonged periods of time. Anyhow soon it was drink'o'clock.


It was great to catch up with my brother at the conference.

RCEM spring CPD day 1 post lunch session

Above picture taken inside Fibber Magee, next to the crown opposite Europa.

Lunch was brilliant with a choice of Irish stew, salmon and tortelloni. I went for Irish stew and probably had one too many potatoes. This was the reason I had to excuse myself from one of the afternoon lectures. Apologies to one of my bosses Dan Horner. However to be fair I have read and referred to his excellent trust guideline on the hospital website many times over the last couple of years. It has always been a pleasure to learn from his in depth knowledge on every aspect of VTE.

Emma Greenwood from Belfast spoke about  her top five medical papers in 2018. LOMAGHI study has conclusively proven the benefit of IV magnesium in atrial fibrillation and I would change my practise on this topic. In pregnant patients with suspected VTE I learnt that d-dimer is relevant and pregnancy adapted YEARS algorithm is a useful decision making tool. I also learnt that there is current evidence which shows no correlation between IV contrast and AKI and the next time there is a delay in imaging due to 'waiting for results', I will be able to counter it with current evidence. OVIVA study has shown the lack of superiority of intravenous antibiotics over oral in orthopaedic infections. However I am not sure I will change current management before this is accepted by orthopaedic colleagues who will be most affected by this change in practise and the medico legal pitfalls are too high to make this change.

Ian Beardshell from Belfast gave an entertaining and energetic presentation on how we are practising emergency medicine the wrong way around. I would not change departmental practise of waiting for investigations until the clinician has seen the patient. However I will try and practise the habit of not looking at the results even before seeing the patient. I think the right order would be ambulance notes, triage notes, history from patient, examine patient, provisional diagnosis including differentials and then look at the results. It was good to have a gentle revision on snouts, spins and likelihood ratio. I am sure I will remember it for another 24-48 hours.

James Shawbrook from Belfast talked about Chest Radiology in ED patients. Key messages were difficult chest drains in loculated pneumo thoraxes(luckily we can leave that headache for the interventional radiologists, however identifying one is our headache), looking at the aortic calcific plaques in relation to the arch of the aorta, use of ECG gated CT to improve imaging(ECG gated CT is a nifty way to scan during the diastolic phase of the heart) and a message as simple as clotted blood is more dense than liquid blood.

Madeline Sampson(Belfast) gave a talk on radiology in blunt trauma. She focused primarily on CXR with useful tips on apical pleural cap, mediastinal shift, mediastinal widening, aortopulmonary window etc. It was a bit of a throw back to pre whole body CT for trauma times. Working in a MTC we often have a low threshold for CT and therefore sometimes often overlook the usefulness of a CXR. Since coming back from the conference I have had at least 2 patients with blunt thoracic trauma who had significant findings on CT which could have been missed on CXR. I do have my sympathies for colleagues in non MTC units where it can be rather difficult to get the radiologist to agree on a CT.

Tajek Hassan(President RCEM) gave a fantastic lecture on various issues he faces as President. He is like a movie star and I enjoyed his candid comments on how difficult the job of the President can be. Political correctness and risk of being misreported by the media is a potential hazard. I think he has done a remarkable job during his tenure and I am certain the president elect Katherine Henderson would continue to build on the work and success of her predecessors. I was disappointed to learn that the Indian foreign office refused to give Dr.Hassan a visa because of his Pakistani ancestry. I am ashamed of this silly stupid behaviour and I hope in future such stupidity does not happen and citizens of both countries can live in peace and visit each other's countries.

That brought us to the end of day 1. The drinks reception was excellent with informal conversations and wine flowing well. The canapes were excellent. Personally it was only marred for me by the unfortunate experience of having a unpleasant conversation with one of the vice presidents of RCEM, who took objection to my comments on twitter about the RCEM presidential elections. I think such behaviour should not happen in a meeting of fellow professionals and it was more like a silly confrontation at 11 pm in a local bar with a drunken man. The vice President of RCEM is a respected position and in a forum of colleagues he should have behaved in a more civil manner irrespective of his feelings about my twitter comments. On my side I can only apologise for my twitter comments and in future will avoid any personal comments on social media.

That's all for now.

More about day  2 and 3 in subsequent blogs.

Ps. Irish whiskey and live traditional music in Irish bars are a delight and I had an excellent evening at the Crown and Fibber Magee.


Picture below taken in Salford Quays. Maybe it will tempt somebody to come work for the excellent team at Salford Royal ED.

Dr.Kumar at RCEM spring CPD 2019

Picture taken inside Fibber Magee and excellent venue for drinks and live Irish music.

I thought I will blog about my first day at RCEM spring CPD for my own benefit and also give a little overview of what happened for the benefit of colleagues who have not been able to to attend.

First of all what a brilliant city Belfast is and I regret not visiting this fantastic city more often which is only an hour away by flight from Manchester. Usual morning registration and coffee with one too many 'light bites' setting me up. Forgot all about the apple on the table. Ian Crawford(Belfast) gave a warm welcome to all in his inaugural speech and then it was soon the first session.

Brendan McGrath(Manchester) spoke about the various presentations and complications we can expect in ED from patients who have a tracheostomies. Main take home message for me was oxygen, secretions, differentiating tracheostomy patient from laryngectomy patients, remembering that they are complex medical patients and there might been an alternative reason for the breathlessness and importance of checking that your department has the right equipment and training for staff. Please check out www.tracheostomy.org.uk, www.globaltrach.org and NTSP app for more information.

Chetan Trivedi(Brighton) spoke about his endeavour to develop a decision rule for when to image in facial injuries. Particularly liked his own personal approach to rule out imaging with safety netting. Take home messages for me where children are different and should rarely be imaged, think of radiation exposure and review existing referrals to maxillo-facial team at local ED. I think we can soon expect a gold standard guideline from him.

Filipe Dhawahir- Scala(Manchester) gave an entertaining talk on when to wake up an opthalmologist. Loved his flamboyant style of presentation. Take home messages don't use cotton bud for removing corneal foreign bodies, ulcers from contact lens use can go badly wrong very soon, importance of identifying papilloedema, identifying the dangerous red eye(Acute Glaucoma), CT in suspected metal projectiles in eye ball(do not waste time doing an X-ray), simplicity of doing a lateral canthotomy and infections in post op patients.  Please have a look at BEECS(British emergency eye care society) and if possible attend one of their annual meetings.

Peter Johns(Ottawa) gave a head spinning talk on vertigo. I managed to stay with him until Dix-Hallpike test, Epley Manouvre, HINTS plus but lost it when he went to Horizontal canal BPPV(apparently 30% of BPPV). Take home message for me was keep revisiting these tests and manouvres, however in practise this is a specialist area and cannot be done in an busy UK emeregency department and there is possible a case for dedicated vertigo clinics in every region. More importantly identifying the patient with a central pathology using HINTS plus and being aware of vestibular migraine as a diagnosis.

Diana Hulbert (Southhampton) gave possibly the most important talk of the day on tried and tested methods for looking after the team in ED. Main take home message was the engage with other members of your team and taking time to know them. I think every senior emergency clinician has a moral responsibility to look after junior colleagues. If we cannot have compassion for our own team then we cannot deliver compassionate treatment for our patients. Learnt about Schwartz rounds for the first time but was even more surprised when a few persons in the audience raised their hands to tell they do it in their departments. I think the college needs to highlight this often neglected part of working in emergency medicine. Personally I have occasionally felt more lonely in a crowded ED than in the middle of a woods.

Chris Moulton spoke about GIRFT(get it right first time) and why it is soon coming to a hospital near you. I think the data gathered from this project will go a long way in having fact based discussions with the management and other specialities. It is still early days but I am sure all emergency departments and physicians will soon be talking about the data gathered from this project. My own person feeling was I wish there was a qualitative element to these quantitative measures because nothing can be more misleading than pure numbers without the qualitative element which can only be provided by qualitative research and assessments.

Soon it was time for lunch. For me it is time to take a shower and head to the conference venue. I will try to keep this going till the end of the conference if I can. If I have not then it is probably because of the excellent Irish Whiskies and hospitality. Have a great day.

Picture taken inside the apartment I am staying in with my brother(he is an emergency physician too).