Management of rib fractures.

Rib fractures are a common reason for hospital admission and are associated with significant morbidity and mortality. This article discusses the management of simple rib fractures and provides practical guidance for junior doctors involved in the care of these patients. Careful assessment to identify patients at high risk of complications is essential and calculation of a rib fracture score can aid management decisions. Pain from rib fractures can be severe and requires multimodal analgesia started promptly and proactively on hospital admission. This may include the use of regional anaesthetic techniques such as thoracic epidurals and erector spinae blocks for patients with significant chest trauma or those at high risk of pulmonary complications.

Finding a solution: Heparinised saline versus normal saline in the maintenance of invasive arterial lines in intensive care.

BACKGROUND: We assessed the impact of heparinised saline versus 0.9% normal saline on arterial line patency. Maintaining the patency of arterial lines is essential for obtaining accurate physiological measurements, enabling blood sampling and minimising line replacement. Use of heparinised saline is associated with risks such as thrombocytopenia, haemorrhage and mis-selection. Historical studies draw variable conclusions but suggest that normal saline is at least as effective at maintaining line patency, although recent evidence has questioned this. METHODS: We conducted a prospective analysis of the use of heparinised saline versus normal saline on unselected patients in the intensive care of our hospital. Data concerning duration of 471 lines insertion and reason for removal was collected. RESULTS: We found a higher risk of blockage for lines flushed with normal saline compared with heparinised saline (RR = 2.15, 95% CI 1.392-3.32, p ≤ 0.001). Of the 56 lines which blocked initially (19 heparinised saline and 37 normal saline lines), 16 were replaced with new lines; 5 heparinised saline lines and 11 normal saline lines were reinserted; 5 of these lines subsequently blocked again, 3 of which were flushed with normal saline. CONCLUSIONS: Our study demonstrates a clinically important reduction in arterial line longevity due to blockages when flushed with normal saline compared to heparinised saline. We have determined that these excess blockages have a significant clinical impact with further lines being inserted after blockage, resulting in increased risks to patients, wasted time and cost of resources. Our findings suggest that the current UK guidance favouring normal saline flushes should be reviewed.

A novel approach to Junior Doctor Induction: A near-peer based curriculum developed and delivered by outgoing Foundation year doctors.

There is a 4-12% increase in mortality in the month following the start of Foundation Year 1 doctors (FY1s) in the UK. In 2012 the National Health Service announced a compulsory shadowing period for FY1s, aiming to increase familiarity with the environment in which the FY1 would be commencing work. There is no national curriculum of the content for this shadowing period and evidence suggests variable content of induction programmes across the UK. Our project aimed to provide a near-peer induction, based on needs previously identified by a national survey and outgoing FY1s' experiences. The day consisted of expert-led lectures, interactive practical sessions delivered by outgoing FY1s, and simulated tasks within the clinical environment where they were about to commence work. The day was evaluated by questionnaires distributed to participants before and after the induction to measure whether there was a change in the perceived confidence of the FY1s in different aspects of their role. There was a 61% improvement in familiarity of equipment and knowing how to request investigations. Confidence levels increased by 45% and 28% in prescribing insulin and intravenous fluids, respectively. There was a 9% improvement in feeling adequately prepared to recognise the critically ill patient. Confidence was high in prescribing intravenous fluids (72% pre-induction and 100% post-induction) and simple analgesics (94% pre-induction and 96% post-induction). The induction day improved self-perceived confidence in all measured areas. The largest increase was in the area given most focus during the day - knowledge of the environment. Combining factual content with orientation of the environment increases confidence for new FY1s. Teaching by outgoing FY1s provides insight into what the job entails. We recommend this style of induction to maximise preparedness within a limited time frame.