Current understanding of epistaxis management amongst junior doctors: a cross-sectional study

Introduction

Epistaxis is one of the most common otolaryngological emergencies and primary care conditions, accounting for 1 in 200 emergency department (ED) presentations (1). Up to 60% of adults experience an episode of epistaxis in their lifetime (2). Epistaxis represents a spectrum of severity ranging from self-limiting bleeding to life-threatening haemorrhage. Adequate initial management can prevent airway and cardiovascular compromise and may avoid inpatient management.

All Australian medical graduates are required to complete an emergency medicine rotation, sometimes in hospitals without onsite Ear, Nose and Throat (ENT) coverage. A recent Australian study found that 70% of medical graduates desired at least 5 days of ENT exposure during their medical degree. However, only roughly a quarter of recent graduates had at least 5 days of exposure or more (3). A previous UK study demonstrated that recent graduates with less than 1 week of ENT experience in medical school had lower levels of confidence in managing epistaxis than their peers (4).

The objective of this study is to gain a current understanding of epistaxis management amongst junior doctors and whether experience in ENT in medical school is linked to greater confidence in epistaxis management. We present this article in accordance with the STROBE reporting checklist (available at https://www.theajo.com/article/view/10.21037/ajo-23-49/rc).

Methods

A cross-sectional survey study was performed with responses collected between March to May of 2023 using Survey Monkey (5). The survey link and QR code were sent to education officers at New South Wales (NSW) and Australian Capital Territory (ACT) hospitals for distribution at intern and resident teaching sessions or via email. All responses were included for data collection. The primary objective was to gain an understanding of epistaxis management in junior doctors. The secondary objective was to analyse whether ENT exposure during medical school was associated with overall confidence in the management principles and practical skills required to manage epistaxis.

Data collected included number of years working as a doctor, amount of ENT exposure both in medical school and as a junior doctor, understanding of basic first aid principles, knowledge of adjuncts to epistaxis management, confidence with silver nitrate cautery, and self-reported confidence in managing a patient with epistaxis. The survey asked respondents 14 multiple choice and open-text questions with Likert scales used for self-reported confidence (Appendix 1). Junior doctors participated voluntarily in this survey without personal or financial incentive.

Statistical analysis was completed via R Studio (6). Fisher’s exact test was used to compare responses from junior doctors with less than 1 week of ENT exposure to those with greater than 1 week. Univariate analysis presented as odds ratios were used when comparing multiple variables.

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) with implied consent from all participants. The project was reviewed by the Northern NSW Local Health District Research Office under a non-Human Research Ethics Committee pathway for low-risk projects and was deemed to be consistent with the principles and values outlined in the National Statement on Ethical Conduct in Human Research [2007]. It was therefore granted exemption from Human Research Ethics Committee approval in accordance with NSW Health policy for low-risk projects.

Results

There were 105 responses from 828 surveys distributed, with a response rate of 13%. There were 52 responses from interns, 38 from residents and 15 from junior doctors with 3 or more years of experience. More than half of the respondents (55.2%, n=58) would advise patients with epistaxis to place pressure on the nasal bones rather than the nasal alae (Table 1). The most common head positioning advice was to flex the neck forward (63%, n=66) and the majority of respondents (76%, n=80) would apply pressure for at least 10 minutes prior to checking haemostasis.

Of the respondents, 74% (n=78) were able to identify an anti-fibrinolytic agent used in management of epistaxis and 65% (n=68) could name a type of nasal packing. All respondents who were able to identify an anti-fibrinolytic agent named tranexamic acid in their answer. Of those who could identify a type of nasal packing, the majority identified a Rapid Rhino (88%, n=60) while the remaining identified ribbon gauze (5.9%, n=4), Merocel nasal pack (4.4%, n=3), and Kaltostat (1.5%, n=1). Two-thirds of respondents (68%, n=71) lacked confidence in their ability to perform silver nitrate cautery for epistaxis. One-quarter of respondents (25%, n=26) were not confident in their ability to manage a patient with epistaxis. Only 19 junior doctors (18%) were able to name a vessel to ligate or embolise in the setting of refractory epistaxis.

Of the total respondents, the majority had less than 1 week of ENT teaching or exposure during medical school (72%, n=76, Figure 1). Respondents with less than 1 week of ENT exposure were six times more likely to advise patients to apply pressure on the nasal bones rather than the nasal alae, compared to those with more than 1 week of ENT experience [odds ratio (OR) =6.3, 95% confidence interval (CI): 2.2–19.9, P<0.001] (Table 2). Of the 76 respondents with less than 1 week of exposure, the majority (82%, n=62) lacked confidence in their ability to perform silver nitrate cautery and the remainder (18%, n=14) were somewhat or fairly confident. By comparison, of the 29 respondents with more than 1 week of exposure, 31% (n=9) were fairly or somewhat confident (P=0.001). There was no significant difference for respondents with less than 1 week of ENT exposure in their knowledge of an anti-fibrinolytic agent (P=0.31) and a type of nasal packing used to manage epistaxis (P=0.65). There was no significant difference in self-reported confidence managing epistaxis between the pooled groups (P=0.25).

Figure 1 Amount of ENT teaching during medical school. ENT, Ear, Nose and Throat.

The majority of respondents (70.4%, n=74) had no post-graduate ENT exposure, whilst 28 respondents (26.7%) reported 4 weeks or less, two respondents (1.9%) reported 5 to 12 weeks and one respondent (1%) reported 3 months or more of ENT exposure. Of the junior doctors with any post-graduate ENT experience, the majority (n=18, 58.1%) would incorrectly advise pressure on the nasal bones rather than nasal alae during epistaxis. This was similar to those respondents with no post-graduate ENT exposure (n=40, 54.1%, P=0.83). Junior doctors with any post-graduate ENT experience were three times more likely to be able to name a type of nasal packing used for management of epistaxis (OR =2.9, 95% CI: 1.1–8.8, P=0.043). There was no significant difference in self-reported confidence with silver nitrate cautery (P=0.80), nor ability to name an anti-fibrinolytic agent (P=0.80) for those with any post-graduate ENT exposure.

Discussion

This cross-sectional study showed that recent Australian medical graduates with less than 1 week of ENT exposure during medical school were more likely to incorrectly advise pressure on the nasal bones rather than the nasal alae during epistaxis. They were also less confident in the technique of silver nitrate cautery. Roughly a quarter of respondents lacked confidence in their ability to manage epistaxis.

Epistaxis represents a common primary care and ED presentation (1). The initial management and stabilisation of patients with epistaxis is often performed by junior medical officers. A Canadian study of primary care physicians and emergency residents found only half of the practitioners would apply correct nasal pressure and appropriate head positioning (7). A UK study of 100 healthcare workers and 100 members of the public found little difference in correct nasal pressure between the groups, highlighting poor education during medical school and as a junior doctor (8). Our study demonstrated similar results, with more than half of the survey respondents stating they would incorrectly place pressure on the nasal bones, indicating a deficiency in basic first-aid principles. Furthermore, silver nitrate cautery is an important skill in initial management of epistaxis and may negate the requirement for nasal packing or hospital admission (9). Two-thirds of the junior doctors surveyed had no confidence in their ability to perform silver nitrate cautery.

Recent graduates with more than 1 week of ENT exposure in their undergraduate education reported higher confidence in silver nitrate cautery and were six-fold more likely to correctly place pressure on the nasal alae compared to their peers. A 2019 survey study showed that recent graduates expect 5 days of ENT teaching during their medical degree but only roughly a quarter achieved this (3). A 2001 survey study of NSW interns reported that 74% of new graduates desired more teaching in nasal packing and nasal examination (10). Our study reported similar results with around three-quarters of respondents having less than 1 week of ENT exposure in medical school. Given the heterogeneity of medical degrees, ENT teaching should be considered during planning of junior doctor education programs as mandated by The Health and Education Training Institute (HETI). It is acknowledged that an ENT attachment for every medical student is not feasible. Specific constraints in medical school placements include lack of ENT services in some hospitals and the volume of students in each clinical rotation block. Particular attention should be paid to practical skills such as correct technique of nasal pressure, nasal packing and silver nitrate cautery as these procedures are relatively simple to perform and potentially lifesaving. The use of e-learning or online training has been shown to be effective in ENT teaching and could warrant consideration (11). Ideally, junior doctors working in ED should have the necessary basic skills to manage most epistaxis cases, with referral for subspecialty management where appropriate.

Respondents with any post-graduate ENT experience were just as likely to incorrectly advise pressure on the nasal bones during epistaxis and had similar self-reported confidence in silver nitrate cautery compared to those with no post-graduate ENT exposure. However, junior doctors with any post-graduate ENT exposure were more likely to correctly identify a type of nasal packing used in management of epistaxis. A 2006 UK study of general practitioners found that those with ENT post-graduate experience were twice as confident in nasal cautery (P=0.002) but overall lacked confidence in epistaxis management compared to those with no post-graduate ENT exposure (12). This may reflect a lack of formal education during ENT rotations as a junior doctor and emphasis should be placed on learning of key practical skills in management of epistaxis. An American study assessing epistaxis knowledge and management amongst nursing staff demonstrated significant improvements in general knowledge about epistaxis and comfort in managing epistaxis following structured education sessions from an ENT resident and nurse educators (13). A similar study looking at educational interventions could be performed in Australia with junior doctors.

Our results mirror a similar UK study cross-sectional survey study, which found 82% of junior doctors lacked confidence in performing nasal cautery, 59% would apply correct nasal pressure during epistaxis and ENT undergraduate exposure was associated with more confidence in managing a patient with epistaxis (P<0.0001) (4). This could possibly be due to similar undergraduate ENT exposure in the UK compared to Australia. The recommendations made for the UK doctors and medical schools have been echoed in this paper and include targeted epistaxis teaching with a particular focus on basic management principles.

Limitations of this study included the low response rate, likely due to email distribution as a voluntary survey. Higher response rates could have been achieved through in-person survey distribution at intern/resident teaching. The response bias limits the overall capture of data from recent medical graduates and reduces the external validity. Furthermore, there was subjectivity of self-reported confidence. It was noted that there was no statistically significant difference between ENT exposure and self-reported confidence in managing epistaxis. However, significant differences were noted in basic first aid principles and silver nitrate cautery, highlighting the subjectivity of self-reported confidence. We acknowledge that Likert scales and questionnaires are inherently impaired by response bias and restricted choice. In addition, no objective information was collected from local medical schools to compare with self-reported ENT teaching from respondents. This may have helped ascertain the degree of recall bias from junior doctors in regards to their ENT experience during medical school.

Given the previously acknowledged issues with ensuring adequate ENT exposure during medical school, we would advocate for practical sessions on epistaxis as part of HETI-mandated intern teaching. Due to high prevalence of epistaxis, all junior doctors should have the requisite emergency skills and confidence in basic management principles.

Conclusions

Our study demonstrated an overall deficiency in first aid principles and basic management of epistaxis amongst junior doctors. Those with more than 1 week of ENT exposure during medical school were more likely to apply nasal pressure correctly and more confident with silver nitrate cautery. If this is not being addressed at undergraduate level, we recommend it is addressed in the junior medical officer curriculum.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/10.21037/ajo-23-49/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-23-49/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-23-49/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-23-49/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) with implied consent from all participants. The project was reviewed by the Northern NSW Local Health District Research Office under a non-Human Research Ethics Committee pathway for low-risk projects and was deemed to be consistent with the principles and values outlined in the National Statement on Ethical Conduct in Human Research [2007]. It was therefore granted exemption from Human Research Ethics Committee approval in accordance with NSW Health policy for low-risk projects.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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