Fascia Iliaca Blocks

Fascia Iliaca blocks are really useful for analgesia for hip fractures. We should be performing them!

Fascia Iliaca or Femoral?
My understanding of this is if we're using a landmark approach, and we use a femoral nerve block the risk of not being in the right soft tissue plane is high. This means that a fascia iliaca block us more likely to be beneficial. The evidence, which I haven't appraised myself, suggests that there's not a significant amount of difference between them all.

Anatomy 

If you look here you can see that the femoral nerve sits, and is enclosed between the fascia lata and the facia iliaca. If you go just lateral to it, you don't know whether you are above or below the fascia iliaca. If you do a fascia iliaca compartment approach, you know you are in the right space.

The podcast from Anatomy for EM is excellent at running through this.

The fascia iliaca compartment contains the three main nerves we are interested in blocking - the femoral nerve, lateral femoral cutaneous and obterator. They provide analgesia for all of the leg except the posterior bit - which the sciatic nerve covers.

Contraindications
· Patient refusal
· Anticoagulation
· Previous femoral bypass surgery
· Inflammation or infection over injection site
· Allergy to local anaesthetics
· Previous femoral bypass surgery

Anaesthetic
We need to use large amounts of local anaesthetic to perform this. 30-40ml should be used for every adult sized patient, and anaesthetic adjusted accordingly.

Our maximum doses are:
Bupivacaine        2mg/kg
Lidocaine            3mg/kg

We normal use 0.25% bupivacaine to provide maximum volume. For a 80kg patient, this would be 160mg which is 60ml of 0.25% bupivacaine. Which is quite a lot. Bupivacaine often works slowly but lasts for a while.

Landmarks 
Place one middle finger on the ASIS and the other middle finger on the pubic tubercle.
Draw a line between these two points.
Divide this line into thirds.
Mark the point 1 - 2 cm caudal from the junction of the lateral and middle third.
This is where you are aiming for.

Ultrasound
Ultrasound for blocks isn't yet common practice. I use it to help avoid accidental intravascular injection - put the probe on where I'm going to inject, and double check.

You can see the two fascial layers on ultrasound, and see the local anaesthetic expand. This video demonstrates the use of ultrasound wonderfully.

Complications
Failure
Infection
Accidental intravascular or intraneural injection
Local anaesthetic toxicity

Links and References
http://www.propofology.com/infographs/fascia-iliaca-block 
http://learned.rocks/cooked-resourced/2016/8/15/nerve-blocks 
http://www.rcemlearning.co.uk/modules/fascia-iliaca-block/ 
https://songsorstories.com/2016/07/31/pop-pop-phew-sounds-to-go-with-blocks/ 
http://www.thegasmanhandbook.co.uk/fascia-iliaca-block.html 
http://stemlynsblog.org/fib-virgil/ 
http://bestbets.org/bets/bet.php?id=2673 

Management part 4 - Complaints

Complaints are unfortunately comment and cost the NHS a lot in time to investigate, and litigation costs. GMC guidance says patients are allowed to complain, and their complaints must be investigated and not bias the care they are provided.
Formal complaints must be made within six months of the event, or the patient becoming aware of the event up to a maximum of a year of the event, by the patient or relative.
The trust has 3 days to acknowledge the complaint, and 25 working days to reply with a response (10 days in primary care).
Always mention PALS

There are three types of claim:
•Category A Claims: below which the trust bears the costs of any settlement (eg £20 000-250000).
•Category B Claims: claims over and above this are settled by the CNST in part (20%)
•Category C Claims: above this threshold (£500 000) settlement paid in full by CNST

To exist, medical negligence requires:
-  Duty of care existed
-  Duty was breached (Bolam/Bolitho tests)
-  Harm occurred as a result of the breach

To get compensation, a patient needs to prove:
That the treatment fell below a minimum standard of competence; and
That he/she has suffered an injury; and
That it is more likely than not that the injury would have been avoided, or less severe, with proper
treatment

 There are six main components of good complaints handling. 

1) Getting it right
2) Being customer focused
3) Being open and accountable
4) Acting fairly and proportionately
5) Putting things right
6) Seeking continuous improvement

When dealing with a complainant, the 3 Rs can be helpful.
Regret
Reason
Remedy

Complaints from GPs
This is not a complaint it's colleague to colleague
Can ring the emailer back, acknowledge mistake, praise their system and make it positive ?audit
Involve GPs in plans/ audit
Local resolution
Datix


http://michael.gradmedic.org/medicine/medicolegal.html#negligence
http://fcemprep.blogspot.co.uk/2014/09/the-fcem-management-viva-basics.html?m=1 

Management Part Two - Disciplinary and Policies

·         Warnings

·         Verbal

·         Written

·         HR issues

• Grievance is an ‘Employee’s complaint’ against management.

• Discipline is a ‘Management’s complaint’ against an employee.

Clinical Issues

- Follow Trainee in Difficulty advice

- NCAS involvement may be necessary 

- An informal route may be decided on 

      Retraining, re-skilling, e.g. workshops, e-learning, 

      Counselling, rehabilitation, e.g. NHS Practitioner Health Programme

      Supervision or development support programme e.g. supervised practice, formative work-based assessments 

       Mentoring or coaching, career guidance

- If needs investigating medical director appoints case investigator. 

- Complete within four weeks 

- If need formal capability hearing, need 20 days notice, 2 members of trust board and one practitioner from outside the Trust. Advice from HR, senior Clinician from outside the trust.

-  Outcomes could be agreement for improvement, formal written warning, final written warning or dismissal. Dismissal needs to be reported to the GMC. 

Referral to the GMC

If:

a. The doctor’s ill health is posing, or may pose, a risk to patients;

b. The doctor refuses, or has failed, to follow advice and guidance from his or her own doctor, occupational health adviser or employer.

c. The doctor’s conduct has led to the involvement of the police and/or the courts or raised other concerns.

Holiday Leave

The annual entitlement under Agenda for Change for each full-time member of staff is:

On appointment              27 days + 8 General Public Holidays

After 5 years service 29 days + 8 General Public Holidays

After 10 years service 33 days + 8 General Public Holidays

Whistleblowing

If concerns speak to CD. If still have concerns anyone can speak to the board.

Management - performance related issues

The FRCEM has a whole management viva. Here are some of my notes on some of the common themes.

• Working practices
• Competencies’
• Team work
• Reliability
• Guidelines / pathways
• Lack of insight
• Sickness
• Probity
• Difficult colleagues / colleagues in difficulty

Speed
Check the numbers before you speak to people about it - facts often don't reflect reality.

Trainee in Difficulty
a nationally accepted phrase used to describe:
a doctor or dentist on a postgraduate training programme, who for whatever reason, needs extra help and support - beyond that which is normally required - to deal with an issue, or issues, that threaten to impede their progress towards completion of a postgraduate training programme
The purpose of identifying a trainee as being “in difficulty” is not to label them; it is to aid the addressing of relevant issues so that they may complete training successfully and continue to contribute to the work of the NHS.
Doctor in difficulty recognises that it’s not just trainees that might be in difficulty – TID is the new term.

If a problem happens, your role initially is not to investigate. You need to ensure safety of:
The patient – go and review them
The staff – support the SHO
Support the SpR and decide if this is a doctor in difficulty.

10 Signs of a Doctor in Difficulty
- The “disappearing act” -  disappearing; lateness; frequent sick leave.
- Low work rate - leaving late and still not achieving a reasonable workload.
- Ward rage - bursts of temper; shouting matches; real or imagined slights
- Rigidity - poor tolerance of ambiguity; inability to compromise; difficulty prioritising; inappropriate ‘whistle blowing’.
- Bypass syndrome - junior colleagues or nurses find ways to avoid seeking the doctor’s opinion or help
- Career problems - difficulty with exams; uncertainty about career choice; disillusionment with medicine
- Insight failure - rejection of constructive criticism; defensiveness; counter-challenge.
- Lack of engagement in educational processes - fails to arrange appraisals, late with learning events/workbased assessments, reluctant to complete portfolio, little reflection
- Lack of initiative/appropriate professional engagement
the trainee may come from a culture where there is a rigid hierarchical structure and trainees are not encouraged to question patient management decisions by senior colleagues, or demonstrate other healthy assertive behaviours
- Inappropriate attitudes
The cultural background may be very strongly male oriented and the trainees may not be used to working with females on an equal status basis

From isolated incidents it is often difficult to know. It is important to report incidents if and when they happen so pattern can be identified.

Causes
Clinical Performance - capability and learning
Health - physical and mental
Personality and Behaviour
Environment - home and work

Management

Early identification of problems
Establish and clarify the facts, with as many sources of information as possible.
Poor performance is a symptom and not a diagnosis.
Clear documentation
Communicate misgivings. Complete records. Remedies must be sought. Progression must be delayed until issues resolved.
Patient safety greater than all

Remain focused on specific problem
Refrain from generalised comment
Deal with the specific behaviour
Try to find positive
Avoid ‘You’ and use ‘I’
Explain how you think
Wait
If facing hostility, state their feelings

Avoid confrontation
Use empathic assertion
Active listening
Control anger
Let their anger subside

When to refer to the GMC 
If the Drs illness is impacting his or her performance, and one or more of:
  Drs ill health is posing, or may pose, a risk to patients
  Dr refuses or has failed to follow advice and guidance from his or her own patients, occy health or employer.
 Drs conduct has lead to the involvement of the police/ and or the courts or raised other concerns.
Discuss potential referrals with GMC or NCAS first.

References
http://stemlynsblog.org/overconfidence-in-the-ed/

http://www.ncas.nhs.uk/ 

http://www.gmc-uk.org/Final_Appendix_5_Trainees_in_Difficulty.pdf_53816759.pdf 

Back Examination

We do back pain examination every day, but it is worth remembering how to do it properly.

- Introduction, Consent, Handwashing, Chaparone. Exposure from the waist up

- Inspection
Inspection from the back and side for:
Cervical lordosis, thoracic kyphosis and lumbar lordosis (lost with age, ank spond, acute disc prolapse).
Cafe au lait spots (neurofibromatosis), hairy patch (spinal dysraphism)
Muscle wasting
Scars

- Palpation
For temperature
  Palpate each spinous process
  Palpate sacroiliac joints
  Palpate paraspinal muscles
Percuss with a fist or tendon hammer (infection, fracture or tumour)

- Move
Lumbar: Lumbar flexion, extension and lateral flexion.
   run hands down side (lateral flexion)
   touch their toes with knees straight (flexion)
   lean backwards with knes straight (extension) - no extension in facet disease.
  Can do a modified Schobers Test - place index and middle fingers 5 centimeters apart and noting how close and far apart they move on the movements.

C-Spine 
Lateral flexion: place your ear on your shoulder;
rotation: look over your shoulder;
flexion: put your chin on your chest;
extension: put your head back to look at the ceiling.

Thoracic 
Fix pelvis and turn

- Special Tests
Straight leg raise - to look for sciatica
Sciatic nerve test - do SLR. When pain brought on, dorsiflex the foot = positive = sciatic!
Bowstring test - SLR. Then lower. Apply popliteal compression = symptoms.

Femoral nerve stretch test - lie prone, passively flex knee - severe = positive.
Tiptoe test - tests S1
Duck walk (on heels) - for L4 power

Neurological examination

References

http://www.osceskills.com/e-learning/subjects/spine-examination/

RSI

There are six separate phases of RSI.

1. Preoxygenation 
  Make sure you use your basic airway adjuncts as needed
  Consider NODSAT


2. Preparation -

pre-assessment - use "LEMON" to see if you think the tube might be difficult
equipment - use a challenge and response checklist to make sure you have remembered everything, even capnography
position patient - find a pillow!
protect c-spine

3. Premedication
    Fentanyl - onset 3 min, offset 20min
       This can be useful in patients who have a head injury

4. Paralysis and Sedation
    Paralysis  - 
    Suxamethonium - depolarising. 1 - 1.5mg/kg bolus
              10-20second onset with 3 - 5 minute offset
    or Rocuronium - 1 - 1.5mg/kg
             Hepatic and biliary excretion so longer offset time and longer onset time

   Sedation 
  Propofol - 1.5 - 2.5mg/kg induction. Maintainence at 1-4 mg/kg/hr
              15-20second onset, 5 - 10min offset
  or Ketamine 
  We don't seem to use Thio or any of the others now.

5. Passage of the ETT - this is the very tricky bit that needs some theatre time!

6. Post intubation care 
  
Complications of RSI
Failure to oxygenate - prevent by using checklist and DAS guidelines

Anaphylaxis - treat with anaphylaxis algorithm

Hypotension - turn down rate of sedation agent. Give small boluses of metaraminol or adrenaline IV to maintain BP.

Laryngospasm - oxygen, Larsens Notch
  Apply PEEP
  If this fails, paralyse and intubate (may be difficult)

Capnography
You need a good seal. If you have a poor trace this might be reflected in your capnography trace.

Basic Airway Management

I hope we're pretty good at this!

Hands:        head tilt chin lift or jaw thrust
Adjuncts:    oropharyngeal airway -hard to hard preferred (middle of incisors to angle of jaw). Soft to soft (tragus to corner of mouth alternative)
                     nasopharyngeal 6mm women, 7mm men (not patient's little finger)
                     supraglottic airway eg. IGel
Tube:           probably as an emergency RSI (see later)

Failed Intubation: 
DAS Guidelines are really simple now and are easy to remember and follow.
Plan A: Intubate
Plan B: Supraglottic
Plan C: Facemask. Paralyse
Plan D: Front of neck surgical cric

Difficult BVM Assessment
M: Mask seal – for example a beard or blood
O: Obesity (BMI >30) and obstruction (snoring history)
A: Age >55
N: No teeth
S: Stiff lungs

Difficult Intubation Assessment 
L: Look: a rapid ‘gut-feeling’ assessment
E: Evaluate the 3-3-2 rule
M: Mallampati score
O: Obesity/obstruction (stridor in particular is worrying)
N: Neck mobility

References and Further Links
http://learning.bmj.com/learning/modules/end/ELU.html?moduleId=10033823 
https://www.das.uk.com/files/das2015intubation_guidelines.pdf