Spinal cases in the ED

Julia Harris Consultant Emergency Medicine Associate Dean Patient Safety

Plan

• My medico-legal practice • Emergency care • Emergency Medical staff • Decision making in ED • Cases • trauma • back pain • neck pain • “odd neurology”??

• Role of EM in investigation

My ML practice 2016-2018Total reports 94 Spinal reports 34

CES 17

“Acute spinal syndrome” Spinal epidural abcess 5

non traumatic cord compression 2

epidural haematoma 3

intramedullary tumour 1

Traumatic fracture 6

Clinical breakdown

Female Male Features

CES 12 5 women mostly mid 30s, men mostly late 50/60s

“Acute Spinal Syndrome”

3 8 IVDU, warfarin, non-non-english speaking, diabetic, on steroids

Trauma 1 5

Themes in ML cases

• Clinical prevalence • Patient centred • Clinical understanding • Barriers to investigations

Clinical prevalence

• Acute spinal syndromes are not common • CES probably commonest so focus on this,

even when neurology doesn’t fit • In the early stages other diagnoses are more

common • thoracic pain/chest pain • fever and back pain

• Cognitive effort to understand the neurology • Penny drops when neurology irrefutable

Patient Centred themes

• Non-english language • Educational status - ?descriptive ability • Vulnerable/marginalised people • Lack of red flag advice • Delays in re-attendance - somehow made

to feel stupid/dismissed by medical staff

Clinician understanding

• “not incontinent/in retention/paralysed so not CES”

• Complex neurology “does not make sense” so not spinal. Patient not believed.

• Lack of adequate micturition history • Use of post-void bladder scan as a proxy for

“not CES” • Only considering CES and imaging lumbar

spine, despite symptoms higher

Barriers to investigations

• OOH access to MRI scans • Spinal teams “requiring an MRI scan

prior to referral” - perception and reality

• Delays to transfer for MRI or spinal review - ambulance response/priority

Emergency Care

Clinical Decision makers• Medical

• F1 - no independent discharge

• “SHO” - F2, core trainees, GP trainees

• Nursing

• ENP - work to protocols

• AHP

• Physiotherapy, OT

• Vulnerable patients support - e.g. frail elderly, drugs and alcohol

Senior Clinical Decision Makers

• Significant workforce gap

• Medical

• Middle grades - trainees and SAS/Clinical Fellow

• Consultants

• Nursing

• ANP/ACP

• Specialty teams

Other support for Junior Doctors in ED

• Specialty teams – on or off site, tertiary referral

• Vulnerable groups – MH/ children/ frail elderly/DV/drugs/

homeless • Hospital at night – smaller hospitals with no or limited

SCDM support within the ED team

Training• Selection

• not everyone wants to do EM??!@

• Induction

• Guidelines and SOP - local and national

• Shop floor supervision

• Educational supervision

• Formal teaching

• Educational curriculum dependent on training pathway

Standards of care• Basic clinical assessment review of vital signs and ambulance/carer/witness

information

• Supervision

• Range of clinical experience and competence

• appropriate referral to a specialty team is an acceptable outcome in some cases

• Referral decision

• referral “viva” vs policies for admission

• Safe discharge and safety netting

• advice sheets, discharge summaries, specialist/hot clinics

Risks and mitigation• “Gatekeeper” access to some investigations - CT, MRI, ECHO

• SCDM “sign off” for high risk investigations and clinical presentations (Senior review)

• ECGs, bedside USS

• chest pain, children under 3 years, headache, abdominal pain

• Notes and investigations review

• “Left before treatment”

High risk times• Handover patients

• End of shift

• Night shifts (weekends)

• fatigue increases error

• less supervision capacity

• End of rotation

• familiarity, breach of protocols

• Just before holidays

• tired, protocol breach

Junior doctors struggle with..• Neurology especially spinal cord

• Multiple injury

• “unexplained” symptoms

• recurrent attenders, chronic pain

• mental health

• rude/aggressive patients

• “difficult’ - drugs, domestic violence, police custody, emotionally unstable personality, homeless, language barrier

• young children

Clinical case 1

• 20 year old man • Motorcross accident • 20-30 mph, thrown • head face and hand

into metal pole • ℅ burning pain to

arms • no neurological signs • Trauma CT scan

Case 2

• 20 year old woman • 3 days after fell and his back of neck

whilst drunk • neck pain, tingling weak hands • on anticoagulant following DVT • neurology - slightly numb hands, weak

grip R>L • Plain x ray and CT scan normal

Case 3

• 28 year old homeless man • Previous IVDU • Severe neck pain “sleeping rough” • No recent trauma • normal temperature (paracetamol by

ambulance crew - in severe pain but “no opiates”!)

• swearing and non-complaint with examination

Case 3

• locally tender in neck • reduced range of

movement in neck • moving arms

“normally” • Bloods slightly high

WCC, no CRP • x ray cervical spine • discharged “home”

Spinal epidural abscess

• average 3-4 attendance too healthcare before diagnosis made

• Classic triad of spinal pain, fever and neurological deficit only 10-15% cases

• only 3/10,000 hospitalised patients • Other diagnoses much more common • Need an MRI for diagnosis

Case 4

• 35 year old woman • Unwell for some months - non specific • Steroids for asthma • diagnosis chronic fatigue • complaint right leg dragging 3/7 • examination - global right leg weakness • some back pain • no sphincter disturbance

Case 4

• Referred spinal team in view of back pain and neurology

• “not CES” so discharged to GP • detailed neurology - sensory changes to

umbilical area • Differential • spinal tumour • epidural bleed • multiple sclerosis

Spinal MS

Spinal tumour

Emergency Treatment in the ED

• Spinal protection - collar or not? • Skin protection • history, examination and investigations • multiple injuries - examination of the

unconscious/unstable patient • needle in a haystack! • CT vs MRI • High spinal injury and ventilation • Autonomic dysreflexia and ED

Why things go wrong

• unselected case mix

• inexperienced junior staff

• time-critical interventions

• insufficient SCDM capacity

• some pejorative decision making

How things go wrong• incomplete basic assessment - cutting corners, workload

related, inexperienced personal judgement, not wishing to perform “that PR exam”

• Pressure to discharge - unsafe clinical decisions made by someone who has not seen the patient, “knowledge” hierarchy

• Dismissing symptoms that cannot easily be explained

• Not listening to parents, carers, nursing staff

• Burnout - loss of empathy, not sleeping

SOPs to help• Cardiac arrest, stroke, major trauma, sepsis teams

• Senior review of high risk conditions

• CDU/Observation wards

• SOPs for specialty reviews (30-60 minutes) and in person

• Checklists - transfers, discharge esp vulnerable patients

• Safety netting policies and advice sheets

The role of EM in investigations

• Recognise the “acute spinal syndrome” • SCDM may have access to MRI • Radiology resistance - ?fear of junior

radiologist of the normal MRI scan OOH • Often refer for “permission” to MRI • Refer to spinal service • on or off site • scan before or after transfer?

Timescales in EM

• Time to be seen • Time for results • Time for specialty

response • Competing pressures -

new sicker patients arriving

• multiple demands for CT scan - priorities?

• ambulance requests - time critical transfers

Summary

• Serious spinal pathology in EM is rare • Early presentations are subtle • Symptoms may be more likely to be alternate

diagnosis • Access to MRI “protected”, esp OOH, weekends • Referral with a clear differential diagnosis is

acceptable • It all takes time and the prevalence means no

pathway exists for these conditions

Thank you