General

#APEM 2012 Highlights

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Thanks to the efforts of Dr. Mark Lyttle (@mdlyttle) APEM 2012 proved to be a resounding success. Here is a selection of some of the hot topics, mainly via the superb tweets of Dr. Natalie May (@_nmay) to fill those in who weren’t there and prompt further discussion and debate. A more detailed twitter feed can be found on my Storify site for Day One and Two and all the presentations will shortly be available via apem.me.uk. The links within the tweets should all work (let me know if not!)

1. Dr. Nick Sargent “Anaphylaxis – an evidence based update”

Not something I had really considered and wonder if I have ever missed this. It does appear studies on adrenaline versus salbutamol for acute asthma have taken place fairly recently http://www.ncbi.nlm.nih.gov/pubmed/16490653

Useful to  consider how your local allergy/anaphlaxis pathways ensure suitable follow up?

2. Dr. Anne Frampton “PEM Training Update”

Although not directly related to the theme of the talk this is causing a lot of concerned conversations

Has your unit fully implemented toxbase guidance (sorry can’t link as password protected) that children should have bloods at 75mg/kg cut off? This technically means the calpol bottle glugger may need investigations when previously they could have gone home. It’s not entirely clear what consultation occurred before this change but consensus was this will result in unnecessary tests.

3. Dr. Mike Clancy “The future of Emergency Medicine”

Mike Clancy emphasised the need for departments to take the bull by the horns in engaging with the new world of commissioning, especially with LETBs . The workforce crisis has been taken on board by the DOH but solutions will not happen overnight.

4. Prof. Ronan O’Sullivan “Paediatric Procedural Sedation – an evidence based approach”

Ronan O’Sullivan has sent up an extensive curriculum around paediatric procedural sedation, in which consent must be obtained even for Nitrous Oxide. The reason being that the mindset created around consenting ensures the proper respect is shown to the procedure. It was great to see some anecdote being supported by other APEM delegates

5. Prof. Adam Finn “The impact of new vaccines in Paediatric Emergency Medicine”

So a number of vaccines will shortly be available in the UK – rotavirus from next year and a flu vaccine. The effects on Paediatric Emergency Departments potentially may be profound. Add in the addition of Men B (potentially) and you are left wondering what we all might be doing in a decade! Some food for thought…

6.  Dr. Natalie May and Dr. Damian Roland “This house believes paediatric Emergency Medicine in the UK would benefit from more doctors in the UK being active on mainstream Social Media”

The against argument is available here

7. Dr. Lisa Munro Davies “Is there a role for ultrasound in Paediatric Emergency Medicine?”

Utilising Ultrasound in Paediatric Emergency Medicine is an inevitable progression as technology advances but the true overall utility has yet to be defined. There was much discussion about the best methods of gaining, developing and maintaining skills. What was clear is the Paediatric Emergency Medicine community would like to be masters of their own destiny in this regard.

Day Two

8. Dr. Anne Kerr ” Should we use Tranexamic Acid in Paediatric Trauma”

TXA has a good safety profile in paediatric surgery but despite the large amount of patients in CRASH-2 we don’t have the paediatric data to know when and in which category of patient to most effectively give it. The RCPCH guidance should promote its use.

9. Dr. Catherine Bevan “Paediatric Cervical Spine Injuries – a pain in the neck?”

An interesting conundrum – true C-Spine injury astonishingly rare but consequences of missing potentially catastrophic. A sharp mind ad flexible thinking required.

10. Dr. Ffion Davies “Paediatric Trauma Networks: the national picture”

It was noticed that whatever national system is put in place there remains not an insignificant number of patients who present with high trauma scores who are brought directly to Emergency Departments by their parents….

11. Dr. Simon Chapman “Simulation in Practice”

Simulation continues to expand but the traditional APLS model is increasingly becoming replaced by more immersive scenarios. Key message was importance of debrief and need for role credibility to be maintained i.e. play the role you actually are!

Thanks for reading!

Social Media

Remember the consciously incompetent: defining what Social Media is and isn’t

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At #APEM2012 Dr. Natalie May (@_nmay) and I gave a talk entitled:

“This house believes Paediatric Emergency Medicine in the UK would benefit from more doctors being active on mainstream social media”

Natalie was “for” and I was (for the sake of the talk) against. Natalie did an excellent presentation (without bullet points and only pictures – @ffoliet would have been proud) and I responded with no audiovisual media (apart from the nativity social media you-tube video) to strengthen my argument (the transcript of the talk and the video can be found here).

A number of unexpected questions and responses came up which I think are useful to share as it is important that social media, #FOAMed and other potentially extremely helpful learning media are not tarred with the wrong brush!

1. Social Media is a concept not one thing (twitter is utterly different from facebook which in turn is not blogging).

2. Facebook ‘scares’ have done the reputation of Social Media significant harm. Health care professionals sticking naked pictures of themselves on their own personal sites does not mean that everyone must follow suit.

2. #FOAMed is a concept that may span many types social media, is certainly not contained by it, and can simply be information via a website…

3. There is great concern that not enough material is quality assured, “…but what if the information is wrong?” we were asked. I found this interesting as it is up to any clinician to decide themselves the quality of information they receive. Does reading one journal article mean you go out and change your practice completely? Do you not weigh up the information, discuss with colleagues and seek other sources of evidence? #FOAMed represents a methodology of the best content percolating upwards to the attention of  interested clinicians. Does everything need to come with a guaranteed evidence based seal of approval? Certainly not in my opinion – what better way to slow things down and stifle debate.

4. Consent and Patient confidentiality cause anxiety, “…but how do you talk about the most interesting, and therefore usually identifiable cases.” This is a very valid concern and has been debated previously (see the comments section). This is not an easy question to answer but in some ways is similar to [3]. In itself not a reason not to engage in the multitude of learning resources out there. Time, experience and legal testing will enable the public and regulators to determine what is appropriate or not but currently there is clear guidance on consent from the GMC (and other healthcare organisations around the world).

I am left with the feeling that the most engaged in developing education 2.0 need to remember they are unconsciously competent and that some work needs to be done to reach the consciously incompetent.

Social Media

An alternative view of social media

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The following is a transcript of the ‘against’ argument at #APEM2012 (www.apem.me.uk)

“Paediatric Emergency Medicine in the UK would benefit from more doctors on mainstream social media”

So let us be clear what we are talking about here. We are talking about social media – the facebook, the linkedIN , the twitter. All the things your children, nephews and nieces get involved with.

Who here has never used any of those things?

Excellent – well done. Clearly hasn’t done you any harm.

Those who support such things would have you believe that by being part of, what is it called  “ a global phenomenon”  that you are somehow missing out.  Missing out on what exactly  – arrogant, self-obessed individuals keen on knowing how many followers they have. We are paediatric emergency medicine specialists; we treat dying children. We don’t follow – we lead! Our knowledge if very valuable – why share it with a community of people you have never met. Much better if it stays within the four walls of the hospital you work; you have the best approach. You must do – no-one has challenged it for it years!

And lets say for the sake of argument I did want to dabble in the nonsense. Who has time for it? With all the google searching, trying to find the one paper you read 5 years ago in a dozen similarly labeled folders, putting together presentations from scratch how can you possibly have any PAs (that sessions for those of you in the US)  left.

And then clearly you will get sued! Remember that chap from Wales.  Posted something along the lines of “don’t like working in birth sheds, prefer the cabbage patch. The public were a little aggrieved when they found out he was talking about obstetric units and ICUs.

This shouldn’t really be a path we go down. A study from the US of 600 staff involved in the admission process for medical schools and residency programmes found that 2/3 were familiar with researching individuals on social networking sites. Furthermore, over half (53%) agreed that online professionalism should be a factor in the selection process and that “unprofessional behaviour” evinced from wall posts/comments, photos, and group memberships should compromise an applicant. Clearly the racous behaviour that the PEM community get up to on the evening of the APEM meal may well count against them in the future? I suppose it was re-assuring that only a small proportion (3-4%) said they used the information they found to reject a candidate.

Although this maybe only a US phenomenon. Jared Rhoads, senior research analyst with CSC’s Global Institute for Emerging Healthcare Practices, said feedback on therapies is one of the most valuable uses for social media — and possibly one of the easiest to facilitate (via amednews).

“If 10,000 people start talking about a side effect of a drug, it won’t be that hard to find that out,” he said. Really???

So basically if you are too busy, already know your stuff and what stay in the ‘real world’ social media is not for you

DISCLAIMER: Dr Damian Roland does not believe a word of the above 😉

Innovation

Innovation or Innovative

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Just some thoughts on terminology rather than technology

There is a great opportunity to once and fall clear up confusion about:

Innovation, innovating and innovators

Innovation – a proven new ‘thing’ that revolutionises, improves value or changes for the better the ways things are done – the emphasis is on the ‘proven’ which may be only in the locality in which it was developed
Innovating – methods of doing something different which have face validity (appear to look good) but may not have proven their worth
Innovators – people who do innovating stuff and sometimes produce an innovation

This is VERY different from implementation which is a challenge in its own right.

An innovating new technology maybe proposed by an innovator and yet it might not be an innovation

An innovation may be brilliant in its location of validation but is only seen as innovating elsewhere because it is difficult to replicate.

So for example a website that promotes innovation must be more than simply a collection of innovators promoting innovating technologies. What we want are innovations which can be implemented elsewhere

Medical Education

Maximising the potential of the NHS e-portfolio

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The implementation of work place based assessments (WPBA) into curricula, partly as a result of the modernising  medical careers programme, has generated a great deal of commentary and angst amongst trainees and trainers[1,2,3]. Recently as a result of communication via twitter a blog – “The NHS Portfolio revolution starts here” has promoted discussion on the use of the e-portfolio. The Academy of Medical Royal Colleges (AoMRC) Trainee Doctors Group (mission statement) met with Karen Begg (ePortfolio Projects Manager at NHS Education for Scotland). Formal minutes of that meeting will be available when approved by the ATDG.  In the interim the following represents some key points to consider when developing future policy. They are the views of the author (Damian Roland and NOT the AoMRC).

  • The e-portfolio is a repository of information and assessments which are devised by individual colleges and the foundation school programme. The educational principles surrounding the delivery and use of WPBA should not be confused with the educational and practical delivery of the e-portfolio.
  • E-portfolios are have been delivered by organizations which also create and define assessment standards, including WPBAs. RPscyh and RCS are examples of this. NHS Education for Scotland delivers portfolios for a number of colleges and although a bespoke interface is devised for each, the underlying construct (and server) is the same. Assessors need consistency in their interfaces but may deal with trainees from a number of difference colleges. This inherently produces difficulties. Reviewing the tradeoff between generic and specialty specific e-portfolio is important.
  • Updating and technological enhancing any large scale electronic interface is a resource intensive activity. Ensuring contracts with developers allow for open source software to be developed may reduce these costs
  • Trainee engagement should occur at all phases of e-portfolio design and testing. Developers, Colleges, and Trainee groups must all work together to ensure representation is occurring and appropriately governed.
  • Training in utilising WPBA and the e-portfolio for Trainees and Assessors (of all grades) must be relevant and obtainable. The GMC’s proposed  accreditation of trainers will be valuable in this regard.

There remain significant challenges to ensuring the assessment of postgraduate medical education training is valid and reliable. Continuing engagement by all parties in a constructive manner is vital but is important that credible change is seen to occur as the status quo is ultimately not in patients best interests

[1] Miller A and Archer J. Impact of workplace based assessment on doctors’ education and performance: a systematic review BMJ 2010; 341 doi: 10.1136/bmj.c5064

[2] Pathan T and Salter M. Attitude to workplace-based assessment Psychiatric Bulletin September 2008 32:359;

[3] Roland D, Brown C, Long A and Newell S. Paediatric Consultants experience of WPBA. Oral presentation at Association of Medical Education Europe Glasgow 2010 and A Trainee’s view of workplace based assessment [NCAT National Multispecialty Conference 2011]

Medical Education

#ASME2012 Favourite Posts

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A collection of my favourite tweets from the Association of the study of Medical Education Annual Conference 2012 (I wasn’t there!)

There is a spectrum from technology-enhanced learning to technology-impairing learning #asme2012

Virtual patients: the teaching should drive the technology design rather than the technology driving the instructional design#asme2012

The distinction between content, outcome and process is important in assessing or evaluating performance in medical education#asme2012

“Students want more formative assessment” – how do anecdotes about what this means differ from literature about what this means?#asme2012

@rakeshspatel @atthepage the missing discourse at #asme2012 – theoretical framings of medical education?

MT @andrewspong: Ten reasons why doctors should use Twitterhttp://bit.ly/NIGIuR | STweM #hcsmeu #hcsmin #asme2012 #hcp#meded @amcunningham

@RonanTKavanagh @nlafferty I have read more journal articles via twitter links than i’ve ever read before. #asme2012 ‏@rakeshspatel

@amcunningham model of care should/is moving to consultant delivered care – trainee numbers are going down – the change will come! #asme2012

“@rakeshspatel: Jane Currie … “There will be more reflection at#asme2012 than in a hall of mirrors!”” I stole that from twitter already!

#ASME2012 preliminary findings on virtual patient design indicate students prefer the simpler linear cases to more complex branching ones

#asme2012 when researchers gave professional med student dilemma scenarios to faculty… There was disagreement +++#professionalism

I think the distinction between ‘expert’ and student is a bit over simplistic… What is an expert, and in which realms? #asme2012

@welsh_gas_doc @dr_fiona there are a few talks at #asme2012about use of WBAs and reflection. Am I naive to think improvements can be made?