John a Sports and Exercise Medicine Consultant in Manchester. He is also Chief Medical Officer for British Triathlon and Visiting Professor in Sport & Exercise Medicine at Manchester Metropolitan University.
Nathan is lead performance nutrition scientist at the English Institute of Sport and at ORRECO.
These two academics take us through how sports science might be able to support our wellbeing during the Covid19 pandemic.
- Recommendations to maintain immune health in athletes https://www.tandfonline.com/loi/tejs20
- Probiotics https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006895.pub3/epdf/full
- Vitamin D and Respiratory Tract Infections: A Systematic Review and Meta-Analysis of Randomized Controlled Trials https://pubmed.ncbi.nlm.nih.gov/23840373/
- Vitamin C for prevention and treatment of pneumonia https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013134/full
- Vitamin C and common cold https://www.cochrane.org/CD000980/ARI_vitamin-c-for-preventing-and-treating-the-common-cold
- Effect of Flavonoids on Upper Respiratory Tract Infections and Immune Function: A Systematic Review and Meta-Analysis https://pubmed.ncbi.nlm.nih.gov/27184276/
- Vitamin C and Infections https://pubmed.ncbi.nlm.nih.gov/28353648/
- Zinc lozenges and the common cold: a meta-analysis comparing zinc acetate and zinc gluconate, and the role of zinc dosage https://pubmed.ncbi.nlm.nih.gov/28515951/
Iain and Simon chat about the current Corona pandemic and the blog in Feb 2020.
Iain remains positive, but Simon thinks the glass is half full. Time will tell who is right (though in truth there is a lot of common ground).
Dr Roberto Cosentini is an old friend of St Emlyn's who works in Bergamo, in Northern Italy. He is right at the heart of the recent Covid19 outbreak. He kindly found an hour to record a podcast with us on his experiences.
There are so many essential lessons in this podcast. Please share with clinical and non-clinical colleagues, as we need to plan NOW. Roberto is quite clear that if we don't train and get plans into place before the wave of cases hit us then both ourselves and our patients will suffer.
In the interest of speed I'm not going to summarise the whole podcast. You have to listen to it all yourself to see what's relevant to you. These are some of my take away messages.
- Divide your department into resp patients and non-resp patients
- Wear PPE and know how to use it
- You will need clinicians who do not usually work in ED. Train and orientate them now (before you need them).
- Most patients are hypoxic and this responds to O2 and CPAP. You're going to need a lot of CPAP and how that happens could be tricky. They found hoods the best (Ed - but how many of those do we have?).
- Although hypoxic, patients have good lung compliance.
- They regularly saw diurnal variation with many patients presenting in the early afternoon.
- It's emotionally exhausting. Prepare yourself and your team psychologically and support them during the pandemic. Roberto's department has an embedded psychologist.
- Health care worker infections were quite low (because they wore PPE for all resp cases).
- Flow through the department and onto wards is absolutely vital.
- Flow out the the main hospitals to other units that can rehabilitate is vital.
- Decisions for ICU level care were similar to normal (in his hospital)
We rarely declare one of our podcasts a 'must listen' but this is an exception. Please listen and share widely. Please think hard about the issues Roberto raises and PLEASE ACT NOW.
How you can support St Emlyn's
- Join us for #stemlynsLIVE conference May 12th 2020
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- Find out more about the MMU MSc in Emergency Medicine here.
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Simon and Zaf talk about the practicialities of REBOA and discuss whether it's ready for prime time in the UK.
Our regular round up of the best of the blog from September 2019. A fairly quiet month for us, but some great content including a fabulous video from Cliff Reid on the Zero Point survey and on a related resus note, the concept of the UK resuscitationist with Dan Horner.
See more on the blog here https://www.stemlynsblog.org/jc-tranexamic-acid-txa-in-head-injury-the-crash-3-results-st-emlyns/
The best from the blog and podcast in July 2019.
Similar challenges, different approaches – Mass Casualty Incident training lessons from Pakistan. St Emlyn’s
Prof. Rick Body is an internationally recognised expert in diagnostic testing. In this podcast he takes us through diagnostics today and also the near future which may change almost everything.
You can read more and see the slides/video at http://www.stemlynsblog.com
This talk focuses on how we can optimise our psychological performance in critical care situations, the type of situations that Simon describes as Time Critical, Information light. The Audio is available below, or watch the full presentation above.
Don't forget to watch the video on the St Emlyn's site http://www.stemlynsblog.org
Here's our regular round up of the blog and podcast from June 2019.
The psychological impact of emergency medicine https://www.stemlynsblog.org/how-events-in-emergency-medicine-impact-doctors-psychological-well-being-st-emlyns/
Can we use IO aspirate for analysis https://www.stemlynsblog.org/jc-can-we-really-use-io-blood-for-analysis-st-emlyns/
Don't forget the Bubbles conference and site https://dontforgetthebubbles.com/
Our regular monthly round up, this month with Ian and Simon chatting through the best of the blog.
The power of peer review: https://www.stemlynsblog.org/smacc2019-the-power-of-peer-review/
Virtual reality in PED: https://www.stemlynsblog.org/jc-virtual-reality-for-distraction-from-paediatric-procedural-pain/
Wellbeing for the broken: https://www.stemlynsblog.org/wellbeing-for-the-broken-part-3-the-podcast-st-emlyns/
Traumatic cardiac arrest https://www.stemlynsblog.org/wellbeing-for-the-broken-part-3-the-podcast-st-emlhttps://www.stemlynsblog.org/jc-should-we-use-chest-compressions-in-traumatic-cardiac-arrest-st-emlyns/
Should we cardiovert AF in the ED or wait? https://www.stemlynsblog.org/should-we-rapidly-cardiovert-af-in-the-ed-st-emlyns/
Prolonged field care in the ED https://www.stemlynsblog.org/prolonged-field-care-in-the-ed/
Keppra or Phenytoin for status epilepticus in kids https://www.stemlynsblog.org/jc-enter-sandman-which-agent-as-second-line-in-paediatric-status-epilepticus/
This is the podcast that accompanies the recent blog post on Jason's latest research on traumatic cardiac arrest and closed chest compressions. This discussion is more wider ranging and explores how the management of TCA has changed, and is changing as we begin to gain a better understanding of the physiological mechanisms underpinning our resuscitation strategies.
Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest.Watts S, Smith JE, Gwyther R, Kirkman E. Resuscitation. 2019 May 9;140:37-42. doi: 10.1016/j.resuscitation.2019.04.048. [Epub ahead of print]
Paediatric traumatic cardiac arrest: the development of an algorithm to guide recognition, management and decisions to terminate resuscitation. Vassallo J, Nutbeam T, Rickard AC, Lyttle MD, Scholefield B, Maconochie IK, Smith JE; PERUKI (Paediatric Emergency Research in the UK and Ireland). Emerg Med J. 2018 Nov;35(11):669-674. doi: 10.1136/emermed-2018-207739. Epub 2018 Aug 28.
Paediatric traumatic cardiac arrest: a Delphi study to establish consensus on definition and management. Rickard AC, Vassallo J, Nutbeam T, Lyttle MD, Maconochie IK, Enki DG, Smith JE; PERUKI (Paediatric Emergency Research in the UK and Ireland). Emerg Med J. 2018 Jul;35(7):434-439. doi: 10.1136/emermed-2017-207226. Epub 2018 Apr 28.
The outcome of patients in traumatic cardiac arrest presenting to deployed military medical treatment facilities: data from the UK Joint Theatre Trauma Registry. Barnard EBG, Hunt PAF, Lewis PEH, Smith JE. J R Army Med Corps. 2018 Jul;164(3):150-154. doi: 10.1136/jramc-2017-000818. Epub 2017 Oct 6.
Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med. January 2015:11-16. doi:10.1177/0141076814560837
May N. Traumatic Cardiac Arrest. St Emlyn’s. http://www.stemlynsblog.org/traumatic-cardiac-arrest/. Published 2012. Accessed 2019.
Alan Grayson takes us through his thoughts on ATLS. Is it really as terrible the #FOAMed world makes out?
This is the podcast that links to the following two posts on how to deal with some of the hardest events we have to deal with in emergency and critical care.
You can read more about the topic on the following two blogs.
This is a tough listen so if you are affected by the content do chat through with colleagues.
Back in late 2018 we gathered in Manchester for the inaugural #stemlynsLIVE conference. Our friend Dr George Wills gave a great talk on Aortic Emergencies.
All emergency physicians know that it's all to easy to miss an aortic catastrophe. Listen to George's wisdom on common pitfalls and top tips to make you a better emergency clinician.
Also check out these excellent #FOAMed resources.
Last year we were honoured to bring Kat Evans to Manchester to talk at the #stemlynsLIVE conference. We've covered emergency medicine in South Africa before on the blog, but there is no substitute to hearing about it from someone who actually works there.
Part of the critical appraisal nuggets series. You can read more here https://www.stemlynsblog.org/cans-critical-appraisal-nuggets-st-emlyns/
Also mentioned in this podcast
1. Definition of p-values on the bottom line https://www.thebottomline.org.uk/blog/ebm/p-value/
2. Fragility index https://lifeinthefastlane.com/ccc/fragility-index/
3. Confidence interval https://en.wikipedia.org/wiki/Confidence_interval
This is a really important concept developed by Charlie Reynard and Rick Body here in Manchester. There is an accompanying paper in the EMJ that you can read via this link https://emj.bmj.com/content/34/12/A870
This concept could radically change how we make probabilistic prescribing decisions in the ED. Have a listen and look out for a blog post on St Emlyn's soon.
This podcast and presentation was recorded at the St Emlyn's LIVE conference in Manchester 2018. In this presentation Clare takes us through the rationale, principles, training and practice that we need in order to continually develop as prehospital and resuscitation practitioners.
You can read more from the event at http://www.stemlynsblog.org
This is a great presentation for anyone interested in continually developing their own and their colleagues practice, delivered by someone who really knows what they are talking about and who works for one of the best developed resuscitation services in the world.
Clare is an Emergency Physician and specialist in Pre-Hospital Care and Retrieval medicine based in Sydney, with Royal Prince Alfred Hospital and Sydney HEMS. She has completed a fellowship in simulation based education, and enjoys training with “real” people - patients, bystanders and the other clinicians we come across as we treat our patients every day. She is a lecturer with the University of Sydney, and is involved in education for the NSW Institute for Trauma Injury Management. When Clare is not working on helicopters or training teams, she is studying yoga or hanging out with her puppy, Archie.
This is the monthly round up of blogs from the St Emlyn's team
Tribalism with Ross Fisher https://www.stemlynsblog.org/breaking-down-tribalism-onetribeemta-st-emlyns/
Conservative management of chest trauma https://www.stemlynsblog.org/jc-conservative-management-of-chest-trauma-st-emlyns/
FeminEM part 4 https://www.stemlynsblog.org/fix18-part-four/
PEP, PEPSE and HIV https://www.stemlynsblog.org/pep-prep-and-all-things-hiv-st-emlyns/
This podcast was recorded at the Intensive Care Society State of the Art meeting in London 2018. Simon Carley interviews Prof Peter Brindley on the interface of technology, humans and humanity in critical care. The audio was recorded live and at the venue so there is a fair bit of background noise, but we hope that this does not distract from a wide ranging and fascinating podcast.
Five strategies to improve your resuscitations.
1. Zero point survey
2. Peer review
3. 10 in 10
4. Hot debriefs
5. Fly the patient
You can read about these strategies, watch the video and learn about the background on the St Emlyn's blog here https://www.stemlynsblog.org/stemlynslive-five-free-strategies-to-improve-your-resuscitation-practice-st-emlyns/
Salim Rezaie from the REBEL EM podcast takes us through the optimal management of cardiac arrest and also explores some of the controversies and difficulties that make the difference to our patients.
You can read a lot more about the background to this talk, see the evidence and watch the video on the St Emlyn's site. Just follow this link. https://www.stemlynsblog.org/beyond-acls-salim-rezaie-at-stemlynslive/
Here's our round up of the best of the blog from October 2018.
In Pursuit of Excellence with Natalie May from #stemlynsLIVE https://www.stemlynsblog.org/in-pursuit-of-excellence/
A FeminEM in NY with Natalie May Part 1. https://www.stemlynsblog.org/fix18-part-one/
JC: Cricoid Pressure, Do we still need it? Simon Carley https://www.stemlynsblog.org/jc-cricoid-pressure-and-rsi-do-we-still-need-it-st-emlyns/
Teaching and Learning in Stretched Environments with Simon Carley https://www.stemlynsblog.org/teaching-and-learning-in-stretched-environments-rsm-2018-st-emlyns/
Five free strategies to improve your resuscitations Simon Carley https://www.stemlynsblog.org/stemlynslive-five-free-strategies-to-improve-your-resuscitation-practice-st-emlyns/
PTSD and me, EMDR therapy with Rusty Carroll https://www.stemlynsblog.org/ptsd-and-me-part-3-emdr-therapy-st-emlyns/
This presentation was given at the inaugural #stemlynsLIVE conference on the 8th of October 2018 in Manchester. You can read more about the presentation and the conference here. https://www.stemlynsblog.org/in-pursuit-of-excellence/
Here's our round up of the best of the blog from September 2018.
The following blogs are discussed.
OOHCA and airway management. Do we need a tube? http://www.stemlynsblog.org/jc-oohca-and-airway-management-do-we-need-a-tube-st-emlyns/
The Zero Point Survey. Optimising resuscitation teams in the ED. https://www.stemlynsblog.org/jc-the-zero-point-survey-optimising-resuscitation-teams-in-the-ed-st-emlyns/
Subacute and massive PE management https://www.stemlynsblog.org/we-call-it-massiiiiiiivve-pe-at-st-emlyns/
EMS Gathering and podcast https://www.stemlynsblog.org/ems-gathering-review-and-podcast-st-emlyns/
ResusTO: A simulation/resuscitation conference like no other https://www.stemlynsblog.org/resusto-a-simulation-resuscitation-conference-like-no-other/
Monkeypox has arrived https://www.stemlynsblog.org/monkeypox-has-arrived-is-the-panic-justified-st-emlyns/
Micro Machines: Sick neonates at RATH18 https://www.stemlynsblog.org/micromachines/
Equality and Diversity in EM. What I learned as a recovering racist. https://www.stemlynsblog.org/equality-and-global-health-what-i-learned-from-being-a-recovering-racist/
StEmlyn's at EusEM (Four posts)
A little later than planned, but here is the podcast round up of the St Emlyn's blog for August 2018.
The following blogs are discussed.
Lessons learned at EMSA https://www.stemlynsblog.org/lessons-learned-at-emsa18/
Troponin and Biotin https://www.stemlynsblog.org/troponin-and-biotin-a-lethal-combination/
Top apps at EMSA https://www.stemlynsblog.org/top-apps-at-emsa18-st-emlyns/
Navigating the CESR route in UK emergency medicine training https://www.stemlynsblog.org/et-tu-brute-one-mans-battle-with-cesr-st-emlyns/
JC: IV fluids review paper https://www.stemlynsblog.org/jc-intravenous-fluid-therapy-in-critically-ill-adults-review-st-emlyns/
Moral Injury in emergency medicine https://www.stemlynsblog.org/moral-injury-in-emergency-and-pre-hospital-care-esther-murray-on-st-emlyns-podcast/
A quick round up of the best from the blog in July 29.
Infinite Game theory and Emergency Medicine with Craig Ferguson
Epinephrine in Cardiac Arrest: Journal Club post (and a really important one)
Keep on Walking: PTSD and me with Rusty Carroll
Tamulosin in Renal Colic: Journal Club post
Pointing the Finger: Paronychia in the ED from Natalie May
Steve Playfor is an paediatric intensive care consultant at the Royal Manchester Children's Hospital here in the 'real' Virchester.
He is an expert in the management of fluid balance in children and has been instrumental in many of the changes to our attitudes, beliefs and practice around IV fluid management.
In this episode Simon and Steve discuss the somewhat crazy story of IV fluid management in kids, the pseudo-science, the custom and practice and finally the potential future of IV management.
I can guarantee that you will learn something here folks.
This month we have a podcast on how we approach patients with mental health needs in the ED. It outlines the rationale and delivery of a change in how we manage some of the most vulnerable patients in the ED. We hope you find it interesting and I suspect you will also find it quite challenging. We are aiming to improve the care of patients with Mental Health needs, but in doing so we must face our own prejudices and practices, which are not always healthy.
Editorial note on language – as you listen to the podcast you might be surprised to hear us use words like ‘insane’ in relation to decisions and systems. In some ways it seems incongruous to use such terms in a podcast that promotes a better understanding of mental health issues. We considered taking them out, but after consideration we left them in an attempt to illustrate the false dichotomy between medical and psychiatric needs that is embedded in much of our work. Perhaps the use of language reflects this and makes the point that we can do better.
Why do we need to rethink our approach to Psychiatric emergencies in the ED?
There are a group of life threatening conditions that present to your ED that you don’t deal with, or at least you don’t deal with very well. This group of conditions has a significant mortality and an incredibly high morbidity, but if you are a typical emergency physician you probably don’t think you own the problem. This group of conditions is at least as common as chest pain and yet it’s unlikely that you feel the same level of ownership of the problem.
The issue is of course that of psychiatric illness. In Virchester it accounts for about 1 in 20 patients through the door, and that number is much, much higher if we were to include substance abuse and its related outcomes.
In general, the approach in many UK units is to divide the patient up on arrival into physical and mental health needs. We feel responsible for the physical problem and then we try and offload any psychiatric problems onto the psychiatrists and mental health teams. At the centre of this is the patient who really does not see or feel this dichotomy and we really need to challenge our approach to this.
Such dichotomies are embedded in our systems. I’m sure that many readers will be familiar with the request to ‘medically clear’ a patient in order that they can then be assessed by the mental health team. Bizareer customs and practice take place around these assessments, for example in Virchester the rule that a patient with a heart rate of more than 100 cannot be medically fit for assessment is sometimes used to decline psychiatric assessment. Such informal rules (none are actually written down or appear in any agreed protocol) result in delayed assessments, patient distress and long waits in the ED. I could go on, and whilst there is good and practice amongst all teams and specialities (we are just as bad at the mental health teams in promoting this dichotomy), the point is that we really don’t act in the patient’s best interests by dividing mental and physical health.
This clear difficulty was one of the starting points for the APEX course, which aims to bring psychiatry and emergency medicine together for the benefit of patients, services and staff.
The interview on the podcast is recorded with Prof. Kevin Mackway-Jones who many of you will know through his work with the Advanced Life Support Group. He was the instigator of APLS at a time when there was a clear need for emergency physicians to improve their approach and knowledge of paediatric emergencies. APEx feels the same. A common condition in our EDs for which we are not currently doing the best that we can for our patients and where a joint teaching and learning approach is needed between the ‘tribes’ of medicine.
This could be a game changer to how we manage a very common and very vulnerable group of patients in the ED.
So what’s on the course?
I can’t give you the whole courses here but there are a few principles that underpin the content and approach.
- It’s co-written and developed between psychiatry and emergency medicine
- It’s a symptom based approach (just like APLS) and so it deals with how we deal with the presenting complaint first and not the underlying diagnosis (as you may not know what this is when you are dealing with the patient).
- The approach will be familiar to many Eps.
- Primary Survey
- Secondary Survey
- Definitive management
- There is a unified approach. The patient needs an ABC approach for physical health, but in addition and concurrently they also need the AEIOU approach.
- A – Assessment of Aggression and Agitation
- E – The Environment in which you are assessing the patient
- I – The Intent of the patient
- O – The Objects the patient has to carry out the intent
- U – The Unified assessment (as you will also be carrying out an ABC assessment alongside AEIOU)
- Rapid tranquilisation is a key conern for EPs and so there is lots on this that does not automatically default to restraint, a needle and syringe and a significant risk.
- Oral tranquilisation works
- Ketamine is not the answer to every patient
- It’s a risk based approach as every intervention (including no intervention) has a risk
Find out more
You can find out more on the ALSG website here.
What has APEx got to do with St Emlyn’s?
At St Emlyn’s we are letting you know about the course for several reasons. Many of us teach and support the work of the ALSG charity (for free and because we believe in it), but also that we all believe that the care of patients with mental health needs can be improved. They are a vulnerable group who generally get a bad deal when they present in crisis to emergency departments. We know we can do better and we believe that this course will help us achieve our goal to do the best that we can for our patients.
- Subscribe to the blog (look top right for the link)
- Subscribe to our PODCAST on iTunes
- Follow us on twitter @stemlyns
- PLEASE Like us on Facebook
- Find out more about the St.Emlyn’s team
- Come join us at our conference in October 2018
Simon and Iain talk through what the team has been up to in April. All the blogs should be on the website and of course you can subscribe to the podcast via iTunes or via PodBean.
Key publications in April.
1. Our e-book on health and wellbeing for the resuscitationist. http://stemlynsblog.org/the-resuscitationists-guide-to-health-and-wellbeing-a-st-emlyns-e-book/
2. Police drop offs for penetrating trauma in the US. http://stemlynsblog.org/to-protect-and-serveand-drop-off-st-emlyns/
3. The latest blogs on the amazing #badEMfest18 conference in South Africa http://stemlynsblog.org/bademfest18-day-3-st-emlyns/
4. The top 10 trauma papers of the year http://stemlynsblog.org/top-10-trauma-papers-2017-2018-for-traumacareuk-conference-st-emlyns/
5. Complications of anticoagulation http://stemlynsblog.org/complications-of-anticoagulation-and-how-to-manage-them-st-emlyns/
6. Trauma CT in kids http://stemlynsblog.org/jc-trauma-paediatric-wbct/
7. The folly of dichotomous diagnosis http://stemlynsblog.org/50-shades-black-white-folly-dichotomy/
8. Bonded in Blood with Ashley Liebig and Noah Gallagher http://stemlynsblog.org/bonded-in-blood/
9. How to coach your team and the Austrian EM conference http://stemlynsblog.org/how-to-coach-feedback-team-st-emlyns/
Gosh, when you write it down and think about all the work the rest of the team puts in to teach and learn it makes me kind of proud. Don't forget to join us later this year for the live version at #stemlyneLIVE in Manchester.