Network Five Emergency Medicine

Theme: Cardiology.

Participants: 

Dr Karan Rao (cardiologist), Dr Nick Moore (ED consultant), Dr Hao Tran (cardiology advanced trainee), David Emmerig (ED trainee), Aran Sandrasegaran, Amanda De Silva, Pramod Chandru, Shreyas Iyer, and Samoda Wilegoda

Discussion:

Boyle, R., & Body, R. (2021). The Diagnostic Accuracy of the Emergency Department Assessment of Chest Pain (EDACS) Score: A Systematic Review and Meta-analysis. Annals Of Emergency Medicine, 77(4), 433-441. https://doi.org/10.1016/j.annemergmed.2020.10.020.

Presenter: David Emmerig.

Credits:
This episode was produced by HETI's Emergency Medicine Training Network 5.

Music/Sound Effects

• Ascension by Keys of Moon | https://soundcloud.com/keysofmoon, Music promoted by https://www.free-stock-music.com
  Attribution 4.0 International (CC BY 4.0), https://creativecommons.org/licenses/by/4.0/. 
• Descriptions by RYYZN | https://soundcloud.com/ryyzn, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Maximalism by Punch Deck | https://soundcloud.com/punch-deck, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Something ’bout July by RYYZN | https://soundcloud.com/ryyzn, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. 
• Sound effects from https://www.free-stock-music.com. 

Thank you for listening!

Please send us an email to let us know what you thought.
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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: Cardiology.

Participants: 

Dr Karan Rao (cardiologist), Dr Nick Moore (ED consultant), Dr Hao Tran (cardiology advanced trainee), David Emmerig (ED trainee), Aran Sandrasegaran, Amanda De Silva, Pramod Chandru, Shreyas Iyer, and Samoda Wilegoda

Discussion:
Green, S., & Schriger, D. (2021). A Methodological Appraisal of the HEART Score and Its Variants. Annals Of Emergency Medicine, 78(2), 253-266. https://doi.org/10.1016/j.annemergmed.2021.02.007.

Presenter: Shreyas Iyer.

Credits:
This episode was produced by HETI's Emergency Medicine Training Network 5.

Music/Sound Effects

• Descriptions by RYYZN | https://soundcloud.com/ryyzn, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Feel It by MBB feat. JV Saxx | https://soundcloud.com/mbbofficial, https://www.instagram.com/JVSAXX/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0, Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US
• Nothing Better by Vendredi ft. ELLE | https://soundcloud.com/vendrediduo, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Medical Examination by MaxKoMusic | https://maxkomusic.com/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
• Sound effects from https://www.free-stock-music.com. 

Thank you for listening!

Please send us an email to let us know what you thought.
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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: Workplace Violence. 

Participants: 

Dr Margaret Murphy, Dr Lex Narushevich, Arvind Karthikeyan, Adamina Drazkiewicz, Aran Sandrasegaran, Amanda De Silva, Pramod Chandru, Harry Hong, Shreyas Iyer, and Caroline Tyers. 

Discussion:
Davids J, Murphy M, Moore N, Wand T, Brown M. Exploring staff experiences: A case for redesigning the response to aggression and violence in the emergency department. Int Emerg Nurs. 2021 Jul;57:101017. doi: 10.1016/j.ienj.2021.101017. Epub 2021 Jun 24. PMID: 34174545. 

Presenter:
Amanda De Silva (emergency medicine trainee at Westmead Hospital). 

Summary: 

• It is widely recognized that emergency departments (EDs) are a high-risk environment when it comes to violence towards healthcare workers. 
• A big contributor to this is the environment in the ED – it is chaotic, messy, busy, and sees a large turnover of patients. Compounded by access block and understaffing, this often exacerbates tense and potentially volatile situations. 
• The Australian College of Emergency Medicine has created a policy regarding violence in emergency departments to provide a guideline by which departments can maintain a safe working environment. 
• They examine the Code Black response and identify important elements of ED design to encourage a positive patient journey through the ED. 
• This observational study was conducted in the Western Sydney Local Health district across four hospitals, one of which is Westmead Hospital. 
• It involved interviewing 20 staff members from across the four sites to gauge their personal experience with violence in the emergency department. The data was analyzed and codes were created to capture concepts in the data. 
• The study identified several points of interest when it comes to Code Blacks. 
• Perpetrators of these events tended to be patients who had presented with drug or alcohol-related illness, as well as mental illness. 
• There are several common triggers of violence, including extensive wait times, frustration/fear/anxiety, and being involuntarily detained for psychiatric care. 
• Staff members feel undertrained when it comes to responding to violence in the ED – 6/20 staff reported not being given formal training when starting their job in ED, while many others reported learning through on-the-job training and observation. 
• Good communication was identified as crucial to managing an escalating situation. 
• Staff members were unsure when to activate a Code Black, and also reported feeling reluctant to call one for fear of interrupting other busy colleagues. 
• There is no culture of formal debriefing after a Code Black, and staff members are often left to manage their own stress. 

Take-Home Points 

• Communication and de-escalation skills are vital to the Code Black response and in preventing violence in the ED. 
• Early escalation of concerns about agitated patients is important, to allow for these communication skills to be utilized and to diffuse escalating situations before they reach a point of physical violence. 
• More education is required around the Code Black response, with particular attention paid to the specific roles of each member of the response team and how they can assist in managing violent situations. 

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Beach by Limujii | https://soundcloud.com/limujii, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. 
• Eternal Sunshine by LiQWYD & Luke Bergs | https://www.liqwydmusic.com, https://www.lukebergsmusic.com
  Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
• Lie 2 You by Leonell Cassio ft. Dylan Emmet | https://soundcloud.com/leonellcassio, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
• Sound effects from https://www.free-stock-music.com. 
• Sittin’ Throwin’ Rocks by Leonell Cassio ft. Lily Hain | https://soundcloud.com/leonellcassio, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.

Thank you for listening!

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: Workplace Violence. 

Participants: 

Dr Margaret Murphy, Dr Lex Narushevich, Arvind Karthikeyan, Adamina Drazkiewicz, Amanda De Silva, Pramod Chandru, Harry Hong, Shreyas Iyer, and Caroline Tyers. 

Discussion:
Jeong, I., & Kim, J. (2018). The relationship between intention to leave the hospital and coping methods of emergency nurses after workplace violence. Journal Of Clinical Nursing, 27(7-8), 1692-1701. https://doi.org/10.1111/jocn.14228.

Presenter:
Dr Arvind Karthikeyan - ED Trainee at Tweed Hospital.

Summary:

• The main aim of this study was to identify the relationship between emergency nurses’ intention to leave the hospital and their coping methods following workplace violence.
• The coping methods were split into emotion-focused and problem-focused mechanisms. 
• The study was a cross-sectional study in which surveys were sent out to 7 hospitals in 7 different cities around Korea (completed by nursing staff working in the emergency department).
• They received 246 returned surveys, and 32 were incomplete, leaving 214 questionnaires to derive their results from.
• Verbal abuse was the most frequent violence experience. 
• Of those who experienced violence, 61% considered leaving the hospital.
• Emotion-focused coping appeared to have a stronger association with nurses’ intention to leave following workplace violence. 
• This highlights the need for resources and processes in place within the emergency department to support staff and encourage healthy coping mechanisms in response to incidents of violence. 

Take-Home Points: 

• This article highlights the importance of healthy coping strategies.
• Having a more formalised, standardised counselling service for healthcare providers would be extremely beneficial (ideally an ‘opt-out’ service). 

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Paradise by MBB | https://soundcloud.com/mbbofficial, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
• Sound effects from https://www.free-stock-music.com. 
• Youth by JayJen & Krishi Sarma | https://soundcloud.com/jayjenmusic, Music promoted by https://www.free-stock-music.com,
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.

Thank you for listening!

Please send us an email to let us know what you thought.
You can contact us at [email protected].

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: Workplace Violence. 

Participants: 

Dr Margaret Murphy, Dr Lex Narushevich, Arvind Karthikeyan, Adamina Drazkiewicz, Aran Sandrasegaran, Amanda De Silva, Pramod Chandru, Harry Hong, Shreyas Iyer, and Caroline Tyers. 

Discussion:
Nikathil, S., Olaussen, A., Symons, E., Gocentas, R., and Mitra, B., 2017. Review article: Workplace violence in the emergency department: A systematic review and meta-analysis. Emergency medicine Australasia : EMA. 29. 10.1111/1742-6723.12761. (Nikathil et al., 2017).

Presenter:
Aran Sandrasegaran - ED SRMO at Westmead Hospital.

Summary:

• Workplace violence in the emergency department is a systematic review and meta-analysis published in 2017 in EMA by Nikathil, et al.
• From 7235 abstracts, 22 studies were deemed relevant.
• A meta-analysis was conducted on the primary outcome variable-proportion of violent patients among total ED presentations.
• A secondary meta-analysis used studies reporting on the proportion of drug and alcohol-affected patients occurring within the violent population.
• It reported the prevalence of violence in Australian Emergency Departments (EDs) as at least 36 events per 10 000 patients, with about 45 in every 100 violent presentations estimated to be associated with alcohol and/or other drugs. These findings had good confidence intervals.
• The study reported that young males were the young (aged between 28-42 years) males were the primary demonstrators of violence.
• Due to statistical heterogeneity in study methodology, definitions and rates, and under-reporting the results are not a full reflection of the incidence of WPV in EDs.  

 Take-Home Points:

• Studies examining violence in the ED consistently report a high prevalence of workplace violence (WPV). Nikithil et al. is the only recent study to confirm a high proportion of violence in terms of patient presentation.
• Drugs and alcohol were commonly associated with violent episodes, often in the absence of an underlying psychiatric diagnosis.
• The findings of this study are likely an underrepresentation due to statistical heterogeneity and under-reporting and analysts and future studies must consider this.
• Public health and legal interventions are urgently required to curb workplace violence in EDs.

References: 

1. International Labour Office/International Council of Nurses/World Health Organization/Public Services International. Framework Guidelines for Addressing Workplace Violence in the Health Sector. Geneva: International Labour Office, 2002.
2. Nikathil, S., Olaussen, A., Symons, E., Gocentas, R., O'Reilly, G. and Mitra, B., 2017. Increasing workplace violence in an Australian adult emergency department. Emergency Medicine Australasia, 30(2), pp.181-186.

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Cinematic Epic Music | Story by Alex-Productions | https://www.youtube.com/channel/UCx0_M61F81Nfb-BRXE-SeVA
  Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License,  https://creativecommons.org/licenses/by/3.0/deed.en_US. 
• Eternal Sunshine by LiQWYD & Luke Bergs | https://www.liqwydmusic.com, https://www.lukebergsmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
• Medical Examination by MaxKoMusic | https://maxkomusic.com/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US. 
• Sound effects from https://www.free-stock-music.com. 
• Vacations by Mehul ShaRma | https://www.instagram.com/mehulsharma4284/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.

Thank you for listening!

Please send us an email to let us know what you thought.
You can contact us at [email protected].

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: 
Christmas Special

Participants: 
Kit Rowe, Harry Hong, Caroline Tyers and Shreyas Iyer.  

Discussion:
Mohammad, M., Karlsson, S., Haddad, J., Cederberg, B., Jernberg, T., & Lindahl, B. et al. (2018). Christmas, national holidays, sport events, and time factors as triggers of acute myocardial infarction: SWEDEHEART observational study 1998-2013. BMJ, k4811. https://doi.org/10.1136/bmj.k4811.

Ferner, R., & Aronson, J. (2020). Harms and the Xmas factor. BMJ, m4067. https://doi.org/10.1136/bmj.m4067.

Presenter:
Caroline Tyers. 

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects 

• Arcade by Flanzen | https://soundcloud.com/flanzen, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Jingle Bells by Alexander Nakarada | https://www.serpentsoundstudios.com, Music promoted by https://www.free-stock-music.com
  Attribution 4.0 International (CC BY 4.0), https://creativecommons.org/licenses/by/4.0/.
• Sound effects from https://www.free-stock-music.com.
• Wakeboard by Scandinavianz | https://soundcloud.com/scandinavianz, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. 
• Winter by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US. 

Thank you for listening!

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: 
Christmas Special

Participants: 
Pramod Chandru, Kit Rowe, Caroline Tyers and Shreyas Iyer.  

Discussion:
Snake Bites - a case from The Australiasian Medical Gazette (from the late 1800s).

Presenter:
Kit Rowe. 

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• We Wish You A Merry Christmas by Alexander Nakarada | https://www.serpentsoundstudios.com, Music promoted by https://www.free-stock-music.com, Attribution 4.0 International (CC BY 4.0), https://creativecommons.org/licenses/by/4.0/. 
• Sound effects from https://www.free-stock-music.com.
• Time by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Time by Mike Leite | https://soundcloud.com/mikeleite, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.

Thank you for listening!

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: 
Christmas Special

Participants: 
Harry Hong, Kit Rowe, Caroline Tyers and Shreyas Iyer.  

Discussion:

Brookfield, C., Phillips, P., & Shorten, R. (2019). Q fever—the superstition of avoiding the word “quiet” as a coping mechanism: randomised controlled non-inferiority trial. BMJ, l6446. https://doi.org/10.1136/bmj.l6446.

Presenter:
Harry Hong - ED trainee at Westmead Hospital. 

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Christmas Is Coming by MaxKoMusic | https://maxkomusic.com/, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.
• Sound effects from https://www.free-stock-music.com.
• Winter by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.

Thank you for listening!

Please send us an email to let us know what you thought.
You can contact us at [email protected].

You can also follow us on Facebook, Instagram, and Twitter!

See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: 
Pulmonary Embolism.

Participants: 
Dr Bristi Roy (respiratory physician), Dr Vanessa Wong (respiratory advanced trainee), Dr Arwen Morath (emergency physician), Dr Pramod Chandru, Kit Rowe, and Caroline Tyers.  

Discussion:
van der Pol, L., Tromeur, C., Bistervels, I., Ni Ainle, F., van Bemmel, T., & Bertoletti, L. et al. (2019). Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. New England Journal Of Medicine, 380(12), 1139-1149. https://doi.org/10.1056/nejmoa1813865.

Presenter:
Dr Vanessa Wong (respiratory advanced trainee at Westmead Hospital).

Summary:

• PE is a leading cause of maternal death in pregnant women. 
• However, the radiation exposure to both mother and foetus involved in the diagnosis of PE remains a complex issue. 
• This is a multi-centre prospective study that utilised the YEARS algorithm (published several years prior) and a D-dimer to predict PE in pregnant women presenting with suspected PE. 
• The study was conducted over a 5-year period from October 2013 to May 2019. 
• It looked at pregnant women over the age of 18 years that had been referred to ED or the obstetric ward with concerns for potential PE.  
• The YEARS algorithm focuses on the 3 elements of the Well’s criteria considered to be the highest yield (being clinical signs of DVT, haemoptysis, and PE as the most likely diagnosis).  
• As part of the algorithm, those patients with clinical signs of DVT underwent a doppler US and were commenced on anticoagulation (and presumed to have a PE) if this was positive for DVT.  
• PE was excluded in those patients without any of the YEARS criteria and with a D-dimer less than 1.0.  
• PE was also excluded in those who had 1-3 of the YEARS criteria and a D-dimer < 0.5, while those with 1-3 of the YEARS criteria and a D-dimer > 0.5 went on to have a CTPA to look for PE. 
• The primary outcome was the cumulative incidence of symptomatic VTE on objective testing during a 3 month follow-up period.  
• The secondary outcome was the proportion of patients in whom CTPA was not indicated to safely exclude PE.  
• There were 510 pregnant women recruited into the study (46% of whom were in the third trimester of pregnancy) with 12 being excluded  
• Of the 498 patients included, 4 had signs and symptoms of DVT with a positive doppler ultrasound. 
• 20 patients of the remaining 494 were diagnosed with PE as part of the pathway. 
• During follow-up, one popliteal DVT was diagnosed, and no patient had PE. 
• CTPA was avoided in 195 patients (39%). 

 Take-Home Points:

• This provides a framework for assessing patients, particularly in the first and second trimesters of pregnancy (and may aid in safely excluding PE without CTPA for low-risk patients). 
• However, in high-risk patients, pursuing a scan remains the most appropriate approach.  

References: 

• van der Hulle T, Cheung WY, Kooij S, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet 2017;390:289-297. 

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Dusk by MusicbyAden | https://soundcloud.com/musicbyaden, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.
• It’s Time by Jay Someday | https://soundcloud.com/jaysomeday, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Magic by Savfk | https://www.youtube.com/savfkmusic, Music promoted by https://www.free-stock-music.com, Attribution 4.0 International (CC BY 4.0), https://creativecommons.org/licenses/by/4.0/.
• My Old East Coast by Vendredi feat. Melanie | https://soundcloud.com/vendrediduo, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Nightswim by Scandinavianz | https://soundcloud.com/scandinavianz, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Sound effects from https://www.free-stock-music.com.
• Tropical Fever by LiQWYD & Luke Bergs | https://www.liqwydmusic.com, https://soundcloud.com/bergscloud, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.

Thank you for listening!

Please send us an email to let us know what you thought.
You can contact us at [email protected].

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

~

Theme: 
Pulmonary Embolism.

Participants: 
Dr Jimmy Chien (senior respiratory physician), Dr Kevin Lai (senior emergency physician), Dr Arwen Morath (emergency physician), Dr Pramod Chandru, Harry Hong, Kit Rowe, and Caroline Tyers.  

 
Discussion:
The Use of PE Response Teams (PERT) in the Care of High-Risk Pulmonary Embolism  

• This is a discussion with senior respiratory physician Dr Jimmy Chien who helped to develop the PERT system at Westmead Hospital. 
• Within this segment, “Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review” by Scott et al, is also discussed. 
• The graphs included in this study are examined closely, so we would recommend reviewing this article while listening to this segment.  

Summary:

• The first place to establish a PE response team was in Massachusetts.  
• It took 2 years to form the PE response team at Westmead Hospital (involving a respiratory physician, an ED physician, an intensivist, an interventional radiologist, a vascular surgeon, and a haematologist). 
• We call a PERT call for patients who have high or intermediate-risk PE.  
• High-risk PE entails a patient with haemodynamic instability (in whom mortality lies between 25-50%). 
• Within the intermediate group, there are two subdivisions: intermediate high-risk (with radiological signs of RV strain with an increase in troponin or pro-BNP) and intermediate low-risk (with either evidence of RV strain OR a troponin rise, or a PE-severity index score class III-IV).  
• When looking within the high-risk PE group, the age group with the worst outcomes (both in PE and with thrombolysis) was those aged > 65 years.  
• The study exploring VA-ECMO in patients with high-risk PE and cardiac arrest (detailed above) also demonstrated that survival rates below the age of 65 years were relatively high, while those over the age of 65 years had a significantly higher mortality rate. 
• The Westmead PERT team has data on 52 patients thus far; of whom 21% were high-risk, 58% were intermediate high-risk and 21% were intermediate low-risk. 
• The most recent analysis of mortality for the Westmead PERT team high-risk PE patients demonstrated a mortality rate of only 10% (compared with the previously stated 25-50%).  

Take-Home Points:

• In addition, the length of stay for these patients managed by the PERT team has been reduced from 13 days pre-PERT to around 8.5 days.  
• The PERT team facilitates high-level nuanced conversations dependent on the clinical judgment, experience, and knowledge of the specialists involved. 
• The development of this PERT team has resulted in improved outcomes for PE patients, and more streamlined care for these patients while in the emergency department and on the ward.  

References: 

• Scott, J., Gordon, M., Vender, R., Pettigrew, S., Desai, P., Marchetti, N., Mamary, A., Panaro, J., Cohen, G., Bashir, R., Lakhter, V., Roth, S., Zhao, H., Toyoda, Y., Criner, G., Moores, L. and Rali, P., 2021. Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism-Related Cardiac Arrest: A Systematic Review*. Critical Care Medicine, 49(5), pp.760-769. 
• Piazza, G., Hohlfelder, B., Jaff, M., Ouriel, K., Engelhardt, T., Sterling, K., Jones, N., Gurley, J., Bhatheja, R., Kennedy, R., Goswami, N., Natarajan, K., Rundback, J., Sadiq, I., Liu, S., Bhalla, N., Raja, M., Weinstock, B., Cynamon, J., Elmasri, F., Garcia, M., Kumar, M., Ayerdi, J., Soukas, P., Kuo, W., Liu, P. and Goldhaber, S., 2015. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism. JACC: Cardiovascular Interventions, 8(10), pp.1382-1392. 
• Herzallah, K., Saleh, Y., Elkinany, S., Abdelkarim, O., Abdelnabi, M. and Almaghraby, A., 2020. Saddle pulmonary embolism successfully managed by thrombus aspiration followed by ultrasound-enhanced catheter-directed thrombolysis. Journal of the American College of Cardiology, 75(11), p.2445. 

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta. 

Music/Sound Effects

• Be Myself by Nettson | https://soundcloud.com/nettson, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Chile by ASHUTOSH | https://soundcloud.com/grandakt, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution-ShareAlike 3.0 Unported, https://creativecommons.org/licenses/by-sa/3.0/deed.en_US.
• Happier by LiQWYD | https://www.liqwydmusic.com, Music promoted by https://www.free-stock-music.com, Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Memories by Roa Music | https://soundcloud.com/roa_music1031, Music promoted by https://www.free-stock-music.com
  Creative Commons Attribution 3.0 Unported License, https://creativecommons.org/licenses/by/3.0/deed.en_US.
• Sound effects from https://www.free-stock-music.com.

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