The St.Emlyn’s Podcast

Ep 266 - Monthly Round Up February 2025 - Skills Fade, Resuscitation Targets and more

In this episode of the St Emlyn's podcast, Iain Beardsell and Simon Carley reflect on their experiences at recent conferences, including the IncrEMentuM 2025 and The Big Sick. They discuss the exceptional quality and innovative formats of presentations at IncrEMentuM, emphasizing the enthusiasm and positive atmosphere. The discussion also covers key emergency medicine topics from February's blog posts, including the maintenance of clinical skills, the importance of diastolic blood pressure in resuscitation, and a systematic review on resuscitative hysterotomy. Additionally, they explore new guidance on the diagnosis of death, particularly in intensive care settings. Special thanks to Galen Pharmaceuticals and PM Cardio for their support.

00:00 Introduction and Recent Conferences

00:42 Highlights from IncrEMentuM 2025

04:47 Emergency Medicine Blog Posts Overview

05:10 Maintaining Competency in Rare Procedures

11:23 Diastolic Blood Pressure in Resuscitation

15:37 Resuscitative Hysterotomy Insights

20:43 Understanding Death Criteria

24:48 Conclusion and Acknowledgements

Ep 231 - February and March 2024 Monthly Round Up - Liver disease, mCPR, Global Health and Elderly patients

After the bumper double paper review episode, we fit two months of blog content into one episode. Iain and Simon discuss the management of the patient with chronic liver disease who has an acute decompensation, global health connections, whether mechanical CPR is more effective than human CPR and the potential effects on elderly patients staying in the ED overnight.

References

Conor Crowley, Justin Salciccioli, Wei Wang, Tomoyoshi Tamura, Edy Y. Kim, Ari Moskowitz, The association between mechanical CPR and outcomes from in-hospital cardiac arrest: An observational cohort study, Resuscitation, 2024, 110142, ISSN 0300-9572, https://doi.org/10.1016/j.resuscitation.2024.110142.

Roussel M, Teissandier D, Yordanov Y, Balen F, Noizet M, Tazarourte K, Bloom B, Catoire P, Berard L, Cachanado M, Simon T, Laribi S, Freund Y; FHU IMPEC-IRU SFMU Collaborators; FHU IMPEC−IRU SFMU Collaborators. Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Intern Med. 2023 Dec 1;183(12):1378-1385. doi: 10.1001/jamainternmed.2023.5961. PMID: 37930696; PMCID: PMC10628833.

Recommended Conferences

Premier Conference - 11th-12th June 2024, Winchester

Tactical Trauma 24 - 7th-9th October, Sundsvall, Sweden

RCEM Annual Scientific Conference

Ep 206 - October 2022 Round Up

In our new regular slot of the middle Monday of the month we're delighted to bring you the highlights from the St Emlyn's blog this month.,

Iain and Simon chat about batching in EDs, Ossilation in decision making and a whole lot more about trauma (chest drains, extrication, sex and TXA and rib fixation).

Please do like and subscribe and keep an eye out for our new sister website St Emlyn's Medical School and it's podcast series coming soon. 

Ep 201 - March/April 2022 Round Up

After a brief hiatus we're back with more from the St Emlyn's Blog. We discuss a wide range of topics from crowding in Emergency Departments and the RePHILL trial to breastfeeding, genetic testing and diagnosing DVTs, as well as our highlights from the recent RCEM CPD Conference in Bournemouth. There really is something for everyone! 

Ep 160 - March 2020 Round Up

Iain and Simon discuss Covid19 and more in this review of the best of the blog from March 2020.

Ep 157 - ICU for the non-intensivist with Sarah Thorton

Simon chats to Sarah Thornton, consultant anaesthetist, intensivist and head of the NW school of anaesthesia on preparing to work in a critical care unit during the Covid-19 pandemic.

Ep 143 - The Future of Diagnostics with Rick Body

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

Ep 142 - Psychological performance in the Resus Room with Ashley Liebig

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

vb

S

Ep 141 - June 2019 Round Up

 

The Paradox of a Good Day in Emergency Medicine: Key Insights

Emergency medicine is a field full of paradoxes, where the definition of a "good day" can differ starkly between healthcare professionals and their patients. This contradiction was a central theme in the discussions from June, which included reflections on the Don’t Forget the Bubbles (DFTB) conference, as well as key topics like the emotional toll of emergency medicine, the evolving nature of adolescent healthcare, and the importance of continuous learning.

Don’t Forget the Bubbles Conference: A Valuable Resource for Pediatric Emergency Medicine

The DFTB conference, held in London this year, has quickly become an essential event for those involved in pediatric emergency medicine. With a focus on both pediatric and adolescent healthcare, the conference offers invaluable insights and practical advice that can benefit even those who primarily work in adult emergency medicine.

One of the standout topics from the conference was the Paradox of a Good Day in Emergency Medicine. This paradox arises from the nature of emergency medicine, where a "good day" for a clinician—filled with successful procedures and exciting cases—often coincides with what is likely the worst day of a patient’s life. This duality highlights the emotional and ethical complexities that emergency physicians must navigate. As practitioners advance in their careers, they often shift from focusing on the technical aspects of their work to becoming more aware of the profound impact these situations have on patients and their families.

The Emotional and Psychological Impact of Emergency Medicine

The emotional burden of emergency medicine was another significant theme at the DFTB conference, especially in sessions led by Kim Holt and Neil Spenceley. Holt, who has been involved in whistleblowing in the high-profile Baby P case, shared her experiences of dealing with criticism and professional challenges. Her story serves as a reminder of the resilience required to navigate the ethical and emotional complexities of healthcare.

Spenceley’s session on doctors in distress emphasized the importance of creating supportive systems within healthcare departments. He argued that instead of focusing on making individuals more resilient, we should design systems that inherently support healthcare professionals. This shift in perspective is crucial in addressing the high levels of burnout and stress among emergency medicine practitioners.

Laura Howard’s research on the psychological well-being of emergency physicians further explored this issue. Her qualitative study, which involved interviews with senior emergency physicians, revealed that the emotional impact of the job affects everyone, regardless of their experience level. Events like traumatic deaths, particularly those involving children or body disruptions, were identified as particularly distressing and had lasting effects on the practitioners involved. Howard’s work underscores the need for robust support systems to help clinicians manage the cumulative toll of their work.

Bridging the Gap in Adolescent Medicine

The DFTB conference also shed light on the often-overlooked area of adolescent healthcare. As healthcare providers, we tend to categorize patients as either adults or children, but adolescents require a tailored approach that addresses their unique needs. Russell Viner, a leader in pediatric healthcare, discussed how the concept of adolescence has evolved over time. In previous generations, adolescence was a brief period between puberty and adulthood, often marked by early milestones like starting a family. Today, however, adolescence is prolonged, with young people delaying traditional markers of adulthood due to social, educational, and economic factors.

This shift has significant implications for how we approach healthcare for adolescents. In our practice, we must ensure that we are not only addressing the physical health of teenagers but also their mental and emotional well-being. This includes creating healthcare environments that are welcoming and appropriate for adolescents and offering resources that cater to their specific health concerns.

Continuous Learning: Beyond ATLS and Traumatic Cardiac Arrest

The importance of continuous learning and staying current with the latest research and best practices was another key message from June. Alan Grayson’s talk on going beyond ATLS (Advanced Trauma Life Support) was particularly impactful. While ATLS has been a cornerstone of trauma care globally, Grayson challenged us to think critically about its limitations, especially in high-income countries where multi-disciplinary teams are the norm.

Grayson emphasized the need to focus on the basics—such as administering tranexamic acid, providing adequate analgesia, and ensuring timely administration of antibiotics—before diving into more advanced interventions like REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta). This back-to-basics approach serves as a crucial reminder that even in a high-tech medical environment, the fundamentals of care are what ultimately save lives.

Jason Smith’s session on traumatic cardiac arrest offered new insights into how we approach this challenging situation. Traditional management has focused on chest compressions, adrenaline, and fluid resuscitation, but emerging evidence suggests that in cases of traumatic cardiac arrest, these interventions may not be as beneficial as once thought. Instead, giving blood and stopping the bleeding were identified as more critical interventions. However, Smith cautioned that this approach should be reserved for hypovolemic cardiac arrest, highlighting the importance of understanding the underlying cause of the arrest before determining the treatment course.

The Reality of Intraosseous (IO) Blood Sampling

A more technical but equally important topic discussed in June was the use of intraosseous (IO) blood sampling. For years, many clinicians have been taught that IO access can provide reliable blood samples for analysis. However, recent evidence suggests otherwise. A systematic review revealed that while it might be possible to obtain certain values like hemoglobin and sodium, the reliability of these results is questionable. Moreover, using IO samples for blood gas analysis or putting marrow through automatic analyzers can lead to equipment malfunction, a concern that has understandably caused anxiety among laboratory staff.

Given this evidence, it’s clear that we need to rethink our approach to IO blood sampling. While it might still have a place in certain situations, particularly for microbiological cultures, relying on IO samples for comprehensive blood analysis is not advisable. This is another example of how continuous learning and critical evaluation of existing practices are essential for improving patient care and ensuring the best possible outcomes.

Conclusion: Moving Forward with Insights from June

As we reflect on the lessons from June, it’s evident that emergency medicine is a constantly evolving field that demands both continuous learning and emotional resilience. Whether through attending conferences like Don’t Forget the Bubbles, staying updated on the latest research, or addressing the psychological impact of our work, it’s clear that adaptation and mutual support are key to thriving in this challenging yet rewarding profession.

At St Emlyn's, we are committed to fostering a culture of lifelong learning, open discussion, and mutual support. As we move into the second half of the year, let’s carry forward the insights we’ve gained, keep pushing the boundaries of our knowledge, and continue to support each other in the demanding yet rewarding field of emergency medicine. Take care, and keep up the incredible work you do.

Ep 140 - GI emergencies with Chris Gray at #stemlynsLIVE

This is Chris's talk from #stemlynsLIVE on GI emergencies. Remember to check out the blog for the background, references and more.

 

Ep 135 - April 2019 Round Up

St. Emlyn's April 2019 Podcast Highlights

Hello and welcome to the St. Emlyn's blog. I'm Simon Carley, and today I'll be sharing the exciting developments from April 2019 on our St. Emlyn's blog. This month has been packed with insightful posts and groundbreaking research, so let's dive in.

Andromeda Shock Trial: A New Perspective

We begin with a thought-provoking journal club post by Dan Horner, an intensivist and emergency physician, who explores the Andromeda Shock trial. This study, conducted in Argentina, compared two resuscitation strategies for patients with septic shock: targeting lactate levels versus peripheral perfusion as measured by capillary refill time.

The Andromeda Shock trial is fascinating because it challenges our reliance on measurable indicators like lactate levels. Many experts argue that lactate doesn't provide the information we think it does about sepsis. Rich Carden's excellent blog on lactate delves into this topic, explaining why the common assumption that lactate indicates anaerobic metabolism is incorrect. Insights from leading intensivists like John Mayberg and Simon Finfer prompt a reevaluation of how we interpret lactate levels.

In the trial, patients managed using peripheral perfusion monitoring showed better outcomes than those managed by lactate levels. Although the trial is underpowered to show definitive differences, the findings suggest that both methods are likely similar in effectiveness. This study highlights the need to reconsider our approach to monitoring septic shock patients and suggests that capillary refill time could be a valuable, low-cost alternative to lactate measurement.

Enhancing Learning with Minimal Effort

Next, we turn to an intriguing blog by Nick Smith, who shares a lazy yet effective way to enhance learning. Inspired by Matthew Walker's book "Why We Sleep," Nick discusses the critical role of rest in learning and retention. The key takeaway is simple: if you're not well-rested before and after learning, you won't retain information effectively.

Nick emphasizes understanding individual learning rhythms. Some people, like early risers, learn best in the morning, while night owls perform better later in the day. This insight is crucial for medical educators and learners alike. For instance, teenagers naturally have later sleep cycles, making early morning learning sessions less effective.

Walker’s book provides compelling evidence on how sleep affects cognitive function and memory consolidation. During sleep, particularly REM sleep, the brain processes and organizes information learned throughout the day. Lack of sleep disrupts this process, leading to poorer retention and understanding.

Nick integrates these scientific insights with practical advice, making his blog an invaluable resource for optimizing learning strategies. He offers tips on improving sleep hygiene, such as maintaining a consistent sleep schedule, creating a restful environment, and avoiding stimulants before bedtime.

Nick also highlights the impact of disrupted sleep patterns, especially when attending international conferences. Jet lag and lack of sleep can severely hamper your ability to absorb new information. Moreover, alcohol consumption negatively affects learning, which is worth considering during conference social events.

Nick's post is packed with practical tips and impressive infographics that make the information easily digestible. It's a must-read for anyone involved in medical education or looking to optimize their learning strategies.

Aortic Emergencies: Key Insights from George Willis

George Willis, a renowned speaker and former professional American football player, presented on aortic emergencies at the St. Emlyn's Live Conference. His talk is a goldmine of information for emergency medicine practitioners. Aortic emergencies, such as ruptured aortic aneurysms and dissections, are critical conditions that require swift diagnosis and management.

George emphasizes using clinical history and tools like ultrasound to diagnose aortic emergencies. For example, ultrasound can identify abdominal aortic aneurysms and dissections via transthoracic echo. He also discusses managing these patients, particularly those with dissections, who present unique challenges due to their unstable blood pressure.

One notable case George describes involves managing pericardial effusion and tamponade resulting from aortic dissection. Techniques like pericardiocentesis can be life-saving, buying valuable time for definitive treatment. George's practical tips and real-world examples make his presentation an invaluable resource for anyone dealing with aortic emergencies.

Managing aortic emergencies requires a nuanced approach, particularly when dealing with unstable patients. George discusses using medications like labetalol for beta-blockade and alpha-blockade to manage blood pressure in dissection patients. These medications help reduce the strain on the aorta without compromising patient safety.

George also covers using imaging techniques, such as CT angiography, to confirm diagnoses and plan interventions. The ability to quickly and accurately diagnose these conditions is crucial for timely surgical intervention, which can significantly improve patient outcomes.

Ambulatory Care for PEs: Dan Horner's Expert Insights

Dan Horner returns with another insightful blog, this time on the ambulatory management of pulmonary embolisms (PEs). At the Arkham conference in Belfast, Dan discussed the benefits and challenges of treating PEs as outpatients. His post is a comprehensive guide to identifying which patients can be safely managed at home and which require hospital admission.

Dan explores various prognostic factors and scoring systems, such as PESI and sPESI, used to predict complications in PE patients. While these scores are better than Gestalt, they are not without limitations. Dan also touches on biomarkers and their role in predicting PE outcomes, though current data is not definitive.

Identifying patients who can be safely managed on an outpatient basis is crucial for optimizing resource use and improving patient comfort. Dan discusses the criteria for outpatient management, including the absence of hemodynamic instability, low bleeding risk, and adequate home support. These criteria help ensure that only patients with a low risk of complications are selected for ambulatory care.

Treatment options for PEs are evolving, with a shift from traditional anticoagulants like Warfarin to NOACs/DOACs. While these newer agents offer convenience, the evidence base is still developing. Dan also addresses the complexities of managing PEs in special populations, such as pregnant patients, highlighting the need for individualized care and informed discussions with patients.

Implementing ambulatory care for PEs requires careful planning and coordination. Dan provides practical advice on setting up ambulatory care pathways, including patient education, follow-up protocols, and the use of telemedicine to monitor patients remotely. He also discusses the importance of multidisciplinary collaboration in managing these patients.

Dan's blog is a treasure trove of resources, including guidelines for outpatient management, risk scores, and follow-up strategies. It's an essential read for anyone involved in the care of PE patients, offering the latest evidence and practical advice.

Coping with Clinical Tragedies: Liz Crowe's Personal Journey

To conclude our April roundup, we have two deeply moving blogs by Liz Crowe, where she shares her experiences of dealing with clinical tragedies. Liz's candid account of a recent tragic event in her professional life resonates with many healthcare professionals who have faced similar situations. Her blogs not only describe the emotional impact of these events but also offer strategies for coping and recovery.

Liz's first blog delves into the profound emotional toll that clinical tragedies can take on healthcare providers. She describes the initial shock, feelings of guilt and helplessness, and the long-lasting impact on mental health. These experiences are not uncommon in the medical field, where the stakes are high, and the outcomes can sometimes be devastating.

Liz emphasizes the importance of acknowledging and processing these experiences, rather than burying the emotions. She provides practical advice on how to support yourself, your colleagues, and your loved ones during such challenging times. Liz's insights are invaluable for anyone in the healthcare field, offering guidance on how to navigate the emotional aftermath of clinical tragedies.

In her second blog, Liz focuses on strategies for coping with and recovering from clinical tragedies. She highlights the importance of seeking professional help when needed, whether through counseling, peer support groups, or other mental health resources. Liz also emphasizes the value of self-care practices, such as exercise, mindfulness, and maintaining a healthy work-life balance.

Liz shares her personal journey of recovery, including the support she received from colleagues and the strategies that helped her regain her confidence and resilience. Her story is a powerful reminder that, while clinical tragedies are deeply challenging, it is possible to heal and continue to provide compassionate care to patients.

Liz's blogs also underscore the importance of building a supportive community within the healthcare profession. She advocates for open conversations about mental health and the emotional challenges of medical practice, fostering an environment where healthcare providers feel safe to share their experiences and seek help.

Liz's blogs are a must-read for anyone who has experienced or is supporting someone through a clinical tragedy. They offer hope and practical strategies for healing and moving forward.

Final Thoughts

April 2019 has been an incredibly insightful month on the St. Emlyn's blog. From groundbreaking research and practical medical education tips to deeply personal reflections on clinical tragedies, we've covered a wide range of topics. Each post offers valuable insights and practical advice for healthcare professionals.

As we continue to face the challenges of a busy emergency department, it's crucial to stay informed and up-to-date with the latest evidence and best practices. Whether you're managing septic shock, improving your learning strategies, diagnosing aortic emergencies, treating PEs, or coping with clinical tragedies, the St. Emlyn's blog has you covered.

The diversity of topics covered this month highlights the importance of continuous learning and adaptation in emergency medicine. By staying abreast of the latest research and best practices, we can ensure that we are providing the highest quality care to our patients.

Thank you for joining us on this journey through April 2019. We hope you find these posts as enlightening and helpful as we do. Stay tuned for more exciting updates and insights from the St. Emlyn's team. Enjoy your emergency medicine practice, and we'll speak to you again soon.

 

Ep 134 - March 2019 Round Up

Highlights from March 2019: Key Insights and Updates

Welcome to the St Emlyn's podcast. I'm Simon Carley and today; I'll be taking you through the highlights from our blog in March 2019. This was a busy month filled with exceptional content, insightful trips, and significant conferences. Let's dive into the details and explore some key topics, starting with adult congenital heart disease, top trauma papers, and the importance of responsible volunteering.

Management of Adult Congenital Heart Disease

March kicked off with an important post on the management of adult congenital heart disease (ACHD). This topic is particularly close to my heart as the hospital I work at is a level two centre for ACHD in the UK. Services have become centralized, and surgical components are now managed at a few specialized centres, with Liverpool being the hub for my region.

Despite this centralization, we still encounter a large population of ACHD patients in our area. These patients often present complex medical histories and unique pathologies that can be challenging to manage in emergency settings. The guidance available typically focuses on chronic and surgical management, but emergency care for these patients requires a different approach.

Common Issues in ACHD Patients

ACHD patients commonly present with dysrhythmias, which can be particularly challenging to manage. Chest pain is also prevalent, although the incidence of ischemic heart disease isn’t significantly higher in ACHD patients, except for those who have undergone certain procedures like the switch operation. Other common issues include:

• Cyanotic patients: Those with single ventricle physiology and right-to-left shunts.
• Endocarditis: A rare but serious complication.
• Non-cardiac problems: Managing ACHD patients with conditions like appendicitis or pneumonia can be complex due to their unique circulatory dynamics.

The bottom line is that these patients often require specialized management strategies. When ACHD patients present with cardiac complications, we consult our local cardiologist or the ACHD centre. However, non-cardiac issues in ACHD patients also warrant discussion with the ACHD centre to ensure comprehensive care.

Key Takeaways for Emergency Physicians

Emergency physicians should familiarize themselves with the unique aspects of Fontan circulation, which relies on venous return based on venous pressure. Aggressive interventions like CPAP, bagging, and diuretics can be detrimental. Understanding these nuances is crucial for providing optimal care.

A Deeper Dive into Fontan Circulation

The Fontan procedure, a surgical intervention for single ventricle defects, creates a unique circulatory system that can be difficult to manage in emergency settings. Unlike normal circulation, Fontan physiology depends heavily on passive blood flow from the veins to the lungs. This means that increasing intrathoracic pressure through methods like CPAP or bagging can reduce cardiac output and worsen the patient's condition.

Fontan patients are particularly vulnerable to fluid shifts and pressures, making careful management of intravenous fluids and medications essential. Understanding these dynamics can be life-saving in the ED. For example, while diuretics might seem a reasonable choice for a patient with fluid overload, they can lead to dangerously low preload and cardiac output in a Fontan patient.

Top Trauma Papers from the Trauma UK Conference

Next up, we revisited some of the top trauma papers presented at the Trauma UK conference. These papers covered a range of topics, from the use of bougies in the ED to bag-mask ventilation during hypertensive resuscitation. Here are some key highlights:

The PAMPer Trial

The PAMPer trial examined the use of prehospital plasma in trauma patients and found significant survival benefits. This trial has important implications for trauma care protocols, emphasizing the potential of early plasma administration to improve outcomes.

The trial showed that administering plasma before hospital arrival can reduce mortality rates in severely injured patients. This finding supports the concept of damage control resuscitation, aiming to stabilize patients early and prevent coagulopathy, acidosis, and hypothermia—the lethal triad in trauma.

Bougie Use in the ED

Another focal point was the utility of bougies in emergency airway management. Evidence suggests that bougies can significantly improve first-pass success rates in difficult intubations, making them a valuable tool in the ED.

A study highlighted at the conference demonstrated that the use of a bougie, even in routine intubations, could increase the success rates for first-pass intubations. This is particularly important in prehospital settings and emergency departments where difficult airways are common.

Late Presenting Head Injury Patients

A paper from Hull explored the management of patients presenting with head injuries more than 24 hours post-injury. The findings indicated that these patients have a significant incidence of important findings on CT scans, suggesting that delayed presentations should not be underestimated.

This study challenges the conventional exclusion of late-presenting head injury patients from acute imaging protocols. It suggests that significant injuries can still be present and warrant immediate attention, even if the patient presents days after the initial trauma.

The Zero Point Survey

The Zero Point Survey, which emphasizes situational awareness, team dynamics, and environmental control before initiating the primary survey, was also highlighted. This approach can significantly enhance resuscitation efforts, ensuring a more organized and effective response.

The Zero Point Survey encourages clinicians to prepare mentally and physically before patient contact. By assessing the situation, assembling the right team, and ensuring the environment is conducive to optimal care, clinicians can improve outcomes and reduce errors in high-stress scenarios.

Responsible Volunteering Overseas

One of the most thought-provoking posts of the month came from Stefan Brisions, discussing the need for responsible volunteering overseas. Volunteering in low and middle-income countries can be incredibly rewarding, but it’s essential to approach it with the right mindset and framework.

The Ethics of Volunteering

Stefan emphasized the importance of volunteering within a system that has sustainability and benefits for all parties involved. There have been concerns about individuals volunteering for personal gain rather than genuine altruism. It’s crucial to ensure that our efforts are focused on creating lasting, positive impacts.

Volunteering should always aim to build local capacity rather than create dependency. This means working with local healthcare providers to enhance their skills and infrastructure, ensuring that the benefits of volunteering continue long after volunteers have left.

Volunteering Responsibly

If you're considering volunteering abroad, it’s vital to engage with established organizations that have a clear mission and ethical framework. This ensures that your contributions are meaningful and aligned with the needs of the local community. Our discussions with experts like Shweta Gidwani, Hooling Harrison, Jennifer Hulls, and Najee Rahman offer valuable insights into this complex issue.

Case Study: Volunteering in South Africa

Kat Evans, who works in Mitchell’s Plain in South Africa, shared her experiences at St Emlyn’s Live. Kat discussed the challenges of working in a resource-limited environment, particularly in managing trauma and toxicology cases.

Her insights into managing trauma in a high-volume, low-resource setting were eye-opening. Kat also shared fascinating details about the use of high doses of atropine for poisoning cases, highlighting the unique medical practices required in such environments.

Kat’s presentation underscored the value of structured volunteer programs that integrate volunteers into local healthcare systems, providing both valuable learning experiences and much-needed support to local healthcare providers.

The Future of SMACC: CODA

March also marked the end of an era with the final SMACC conference in Sydney. SMACC has been a cornerstone for many in the emergency and critical care communities, offering unparalleled opportunities for learning and networking. However, the spirit of SMACC lives on in its successor, CODA.

CODA: A New Beginning

CODA aims to build on SMACC's successes while addressing broader health issues such as vaccination, climate change, and healthcare inequality. The goal is to leverage the engaged community SMACC created to drive meaningful change on a global scale.

CODA plans to tackle these global health issues by bringing together a diverse group of professionals, including those outside the traditional medical fields. This interdisciplinary approach aims to create innovative solutions to some of the world’s most pressing health challenges.

Looking Ahead

While we bid farewell to SMACC, we look forward to the new opportunities CODA will bring. Its emphasis on tackling significant health challenges aligns with the evolving needs of the global healthcare community, promising an exciting future.

What to Expect from CODA

CODA will continue the tradition of high-quality content and dynamic presentations that SMACC was known for. However, it will also incorporate new elements focused on global health advocacy and interdisciplinary collaboration. Expect to see more discussions on how healthcare professionals can contribute to solving broader societal issues.

Additional Highlights from March

Critical Appraisal Nuggets (CANS) on P-values

We also introduced a mini podcast series called Critical Appraisal Nuggets (CANS) focusing on p-values, featuring myself and Rick Body. P-values are a common topic in exams and critical appraisal, and understanding them is crucial for interpreting medical research.

This less-than-ten-minute podcast provides a concise overview of p-values, helping clinicians and students alike grasp this important concept. By demystifying p-values, we aim to enhance our audience's critical appraisal skills, enabling better evidence-based practice.

Dual Coding in Medical Education

Nick Smith, a recent addition to the St Emlyn's team and a brilliant clinical educator, shared insights on dual coding. Dual coding involves using both verbal and visual information to enhance learning and retention.

Nick’s post emphasized how our brains struggle to process multiple streams of information simultaneously. Effective teaching and communication require a balance between verbal explanations and visual aids, ensuring that learners can absorb and retain information without being overwhelmed.

The Impact of Reboa in Trauma Care

Zaf Qasim, a great friend of ours over in the US, examined the impact of Resuscitative Endovascular Balloon Occlusion of the Aorta (Reboa) in trauma care. This post, based on a paper published in JAMA Surgery, analyzed Reboa success rates in civilian trauma using a US database.

The findings suggested that Reboa was associated with higher mortality rates compared to similar patients who did not receive Reboa. This raises important questions about patient selection and the overall benefits of Reboa in trauma care.

Zaf’s post highlighted the need for ongoing research and evidence to determine Reboa's true value. While there are compelling pathophysiological arguments for its use, the clinical outcomes must be scrutinized to ensure it is applied appropriately and effectively.

The Role of Evidence-Based Practice

At St Emlyn's, we prioritize evidence-based practice in all aspects of emergency medicine. The discussions around Reboa, p-values, and dual coding all reinforce the importance of using high-quality evidence to guide clinical decisions and educational strategies.

Final Thoughts

March 2019 was a month of incredible learning and growth. From managing complex ACHD patients to discussing the ethics of volunteering and exploring cutting-edge trauma research, we covered a wide range of topics that are crucial for emergency medicine professionals.

Stay Connected

As we move forward, we encourage you to stay connected with St Emlyn’s for more insights, updates, and discussions. Follow our blog, participate in our events, and join the conversation on social media. Together, we can continue to advance the field of emergency medicine and make a difference in the lives of our patients.

Thank you for joining us this month. Enjoy your practice, and we’ll be back with more great content in April. Have fun, stay safe, and keep learning!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ep 133 - February 2019 Round Up

 

Exploring the Latest in Emergency Medicine: February 2024 Edition

Hello and welcome to the St Emlyn's Podcast! I’m Simon Carly, and today, albeit a little later than planned, I'll be diving into the fascinating February papers and blogs that have graced the St Emlyn's Podcast. If you missed out in February, fear not—you can always revisit the archives on our blog. It’s all there, waiting for you to explore. Let’s take a deep dive into what made February such an exciting month in emergency medicine.

A Journey to Jeddah: Bridging Borders in Emergency Medicine

In February, I had the distinct honour of travelling to Jeddah, Saudi Arabia, to join the Saudi Arabian Society of Emergency Medicine. Jeddah is a city brimming with activity and change. Despite Saudi Arabia being vastly different from the UK, I found common ground with the emergency physicians there. Many of them have trained abroad in Canada, the US, and the UK, making them kindred spirits with shared values and ideas in treating emergency patients.

During my visit, I was invited to present the top ten trauma papers, a task I thoroughly enjoy. These papers, detailed on our website, included highlights like the PAMPER trial and airway management papers around cardiac arrest. We also delved into studies beyond trauma, such as the Airways 2 study on superox in critically ill patients and intubation with ED use of bougies, which we advocate at St. Emlyn’s. Additionally, the conservative management of pneumothoraces, a topic we've discussed before, is becoming increasingly recognized as safe, especially for traumatic pneumothoraces visible only on CT scans.

PTSD and the Road to Recovery: Insights from Rusty Carroll

Our friend and colleague, Rusty Carroll, has shared another compelling post on PTSD. Rusty’s previous blogs detailed his recovery journey from PTSD, stemming from his work in the ambulance service. His latest update brings us into his post-therapy life as he navigates a new, rewarding, and successful path. For anyone experiencing PTSD or knowing someone who is, Rusty's series is invaluable. His journey may differ from yours, but understanding that there is a path to recovery is incredibly encouraging.

PTSD is a serious issue that affects many healthcare professionals, and Rusty’s openness about his struggles and recovery provides a beacon of hope for others. His posts cover various aspects of his journey, from the initial recognition of symptoms to the therapeutic interventions that helped him reclaim his life. Rusty emphasizes the importance of seeking help, breaking the stigma associated with mental health issues, and supporting colleagues who may be going through similar experiences.

Understanding Trauma Mortality: A Shift in Focus

In our journal club, we explored why bleeding trauma patients die. This editorial by Karen Broe and John Holcomb in Critical Care Medicine challenges our preconceptions about trauma mortality. The implementation of pre-hospital systems, emergency management, and damage control surgery has significantly reduced pre-hospital deaths. However, this has shifted mortality to the emergency department's early hours and even later, 24 hours down the line.

We are now seeing deaths caused by late systematic immunosuppression, persistent inflammation, and catabolism syndromes. Despite successful initial management, patients are still succumbing later on. This shift indicates that our trauma story is far from complete. More research is needed to understand and address these late-phase deaths, suggesting that critical care phases hold the key to future advancements.

This new understanding prompts us to reconsider our approaches in trauma care. While we have made significant strides in reducing early mortality, the challenge now lies in managing these complex late-phase issues. This involves multidisciplinary collaboration, innovative research, and a commitment to continuous improvement in trauma care protocols.

Reevaluating PE in Syncope: A Fresh Perspective

Natalie May published a follow-up paper related to the PESIT study, which had previously suggested a high incidence of pulmonary embolism (PE) as a cause of syncope. This controversial study, conducted in Italy, sparked debates across various platforms, including EM Nerd, EMCrit, Emlyns Note, and Rebel EM.

However, new research from the North American Syncope Consortium reveals a much lower prevalence of PE among emergency department patients with syncope. This is a significant finding, as it challenges the alarming figures from the PESIT study. It allows us to return to our previous practices of using well-established tools like Wells' scoring and PERC scoring without the heightened fear of PE being the primary cause of syncope.

Natalie’s analysis provides a balanced perspective, highlighting the importance of context in interpreting study results. The discrepancy between the PESIT study and the North American Syncope Consortium's findings underscores the need for ongoing research and validation of clinical guidelines. As emergency physicians, staying informed about such developments ensures that we provide the best care based on the latest evidence.

Philosophy of Emergency Medicine: Workplace Relationships Matter

Stefan Brzezins contributes a thought-provoking post on the importance of workplace relationships. Stefan, a colleague who has worked in South Africa and now the UK, highlights how our interactions with colleagues significantly impact our behaviour, happiness, and departmental efficiency. Dysfunctional departments often correlate with poor personal relationships among consultants and senior nurses, ultimately affecting patient care.

Stefan's advice includes not taking unnecessary offence, showing gratitude, celebrating the good news, and fostering teamwork. While these may seem obvious, their implementation can transform workplace dynamics. Reflecting on Stefan's insights has prompted me to reevaluate my practices and strive for better interpersonal relationships at work.

Good workplace relationships are foundational to creating a supportive and effective healthcare environment. When colleagues communicate openly, show appreciation for each other’s efforts, and work collaboratively, they experience higher job satisfaction, reduced stress, and, ultimately, better patient outcomes. Stefan’s post serves as a reminder that the human element of healthcare is just as important as the clinical skills we bring to our practice.

Ventilation During RSI: Revisiting Established Practices

Another significant post examines whether we should continue ventilation during rapid sequence intubation (RSI). Traditional teaching discouraged ventilation during the apnea period due to safety concerns. However, for critically ill patients with low oxygen saturation, not ventilating can lead to severe hypoxia.

A randomized control trial in the ED assessed the safety of ventilation during this period. The study found that patients who were ventilated during the apnea period had less oxygen desaturation without significant adverse effects. While the study's sample size is small, it supports our evolving practices and aligns with our experiences. However, it is crucial to critically assess the study's methodology and incorporate this knowledge cautiously into clinical practice.

This trial’s findings challenge the long-standing dogma of no ventilation during RSI, pushing us to rethink and potentially update our protocols. As emergency medicine evolves, we must remain flexible and willing to adapt our practices based on emerging evidence. Ensuring that our approaches are both safe and effective is paramount to improving patient outcomes.

The Role of Scribes in the ED: Efficiency and Quality Improvement

Chris Gray's post on the use of scribes in the ED follows a previous discussion on this topic. Scribes can save time and improve documentation quality, which is vital in a high-pressure environment. A randomized control trial demonstrated that scribes do save time, though the effect size was modest. The potential for better documentation quality is equally important, making scribes a valuable addition to emergency departments. We are keen to hear from anyone using scribes in the UK, as this practice is more common in the US.

The use of scribes can enhance the efficiency of emergency departments by allowing physicians to focus more on patient care rather than administrative tasks. Improved documentation can also lead to better patient tracking, follow-up, and overall care quality. As our healthcare systems become increasingly strained, innovations like scribes offer practical solutions to maintain high standards of care.

Reflecting on February: A Busy Month in Emergency Medicine

February was packed with insights and developments in emergency medicine. From international collaborations and trauma management advancements to revisiting PTSD recovery stories and philosophical reflections on workplace relationships, the month offered a wealth of knowledge. As we move into March, we look forward to sharing more exciting updates, including coverage of the SMACC conference.

The diversity of topics covered in February highlights the multifaceted nature of emergency medicine. Each paper and blog post contributes to a broader understanding of how we can improve patient care, support our colleagues, and adapt to new challenges. This continuous learning process is what makes emergency medicine such a dynamic and rewarding field.

Supporting the St Emlyn's Podcast: Your Contribution Matters

Since 2012, we've funded the blog and podcast out of our own pockets. As our audience grows, so do our expenses. If you find our content valuable and wish to support us, please consider making a small donation or subscribing regularly. Your contributions help us keep St Emlyn's a free, open-access medical education resource for all.

By supporting the St Emlyn's Podcast, you enable us to continue delivering high-quality, evidence-based content to the emergency medicine community. Your donations help cover the costs of hosting, producing, and distributing our materials, ensuring that we can reach a global audience of healthcare professionals.

Conclusion

The February edition of the St Emlyn's Podcast provided a rich tapestry of insights and developments in emergency medicine. From my journey to Jeddah and the fascinating trauma studies to the personal stories of PTSD recovery and the philosophical reflections on workplace relationships, there was something for everyone.

Our exploration of new research, such as the reevaluation of PE in syncope and the safety of ventilation during RSI, underscores the importance of staying informed and adaptable in our practice. Meanwhile, discussions on the role of scribes and the significance of workplace dynamics highlight the multifaceted challenges we face in emergency medicine.

As we look forward to March and beyond, we remain committed to bringing you the latest in emergency medicine and fostering a community of continuous learning and improvement. Thank you for joining us on this journey, and we appreciate your support in keeping St Emlyn's a vital resource for all.

Stay tuned for more insights, updates, and discussions. Until then, keep pushing the boundaries of emergency medicine, supporting your colleagues, and striving for excellence in patient care. Have a great time, and we’ll be back with you shortly.

 

Exploring the Latest in Emergency Medicine: February 2024 Edition

Hello and welcome to the St Emlyn's Podcast! I’m Simon Carly, and today, albeit a little later than planned, I'll be diving into the fascinating February papers and blogs that have graced the St Emlyn's Podcast. If you missed out in February, fear not—you can always revisit the archives on our blog. It’s all there, waiting for you to explore. Let’s take a deep dive into what made February such an exciting month in emergency medicine.

A Journey to Jeddah: Bridging Borders in Emergency Medicine

In February, I had the distinct honour of travelling to Jeddah, Saudi Arabia, to join the Saudi Arabian Society of Emergency Medicine. Jeddah is a city brimming with activity and change. Despite Saudi Arabia being vastly different from the UK, I found common ground with the emergency physicians there. Many of them have trained abroad in Canada, the US, and the UK, making them kindred spirits with shared values and ideas in treating emergency patients.

During my visit, I was invited to present the top ten trauma papers, a task I thoroughly enjoy. These papers, detailed on our website, included highlights like the PAMPER trial and airway management papers around cardiac arrest. We also delved into studies beyond trauma, such as the Airways 2 study on superox in critically ill patients and intubation with ED use of bougies, which we advocate at St. Emlyn’s. Additionally, the conservative management of pneumothoraces, a topic we've discussed before, is becoming increasingly recognized as safe, especially for traumatic pneumothoraces visible only on CT scans.

PTSD and the Road to Recovery: Insights from Rusty Carroll

Our friend and colleague, Rusty Carroll, has shared another compelling post on PTSD. Rusty’s previous blogs detailed his recovery journey from PTSD, stemming from his work in the ambulance service. His latest update brings us into his post-therapy life as he navigates a new, rewarding, and successful path. For anyone experiencing PTSD or knowing someone who is, Rusty's series is invaluable. His journey may differ from yours, but understanding that there is a path to recovery is incredibly encouraging.

PTSD is a serious issue that affects many healthcare professionals, and Rusty’s openness about his struggles and recovery provides a beacon of hope for others. His posts cover various aspects of his journey, from the initial recognition of symptoms to the therapeutic interventions that helped him reclaim his life. Rusty emphasizes the importance of seeking help, breaking the stigma associated with mental health issues, and supporting colleagues who may be going through similar experiences.

Understanding Trauma Mortality: A Shift in Focus

In our journal club, we explored why bleeding trauma patients die. This editorial by Karen Broe and John Holcomb in Critical Care Medicine challenges our preconceptions about trauma mortality. The implementation of pre-hospital systems, emergency management, and damage control surgery has significantly reduced pre-hospital deaths. However, this has shifted mortality to the emergency department's early hours and even later, 24 hours down the line.

We are now seeing deaths caused by late systematic immunosuppression, persistent inflammation, and catabolism syndromes. Despite successful initial management, patients are still succumbing later on. This shift indicates that our trauma story is far from complete. More research is needed to understand and address these late-phase deaths, suggesting that critical care phases hold the key to future advancements.

This new understanding prompts us to reconsider our approaches in trauma care. While we have made significant strides in reducing early mortality, the challenge now lies in managing these complex late-phase issues. This involves multidisciplinary collaboration, innovative research, and a commitment to continuous improvement in trauma care protocols.

Reevaluating PE in Syncope: A Fresh Perspective

Natalie May published a follow-up paper related to the PESIT study, which had previously suggested a high incidence of pulmonary embolism (PE) as a cause of syncope. This controversial study, conducted in Italy, sparked debates across various platforms, including EM Nerd, EMCrit, Emlyns Note, and Rebel EM.

However, new research from the North American Syncope Consortium reveals a much lower prevalence of PE among emergency department patients with syncope. This is a significant finding, as it challenges the alarming figures from the PESIT study. It allows us to return to our previous practices of using well-established tools like Wells' scoring and PERC scoring without the heightened fear of PE being the primary cause of syncope.

Natalie’s analysis provides a balanced perspective, highlighting the importance of context in interpreting study results. The discrepancy between the PESIT study and the North American Syncope Consortium's findings underscores the need for ongoing research and validation of clinical guidelines. As emergency physicians, staying informed about such developments ensures that we provide the best care based on the latest evidence.

Philosophy of Emergency Medicine: Workplace Relationships Matter

Stefan Brzezins contributes a thought-provoking post on the importance of workplace relationships. Stefan, a colleague who has worked in South Africa and now the UK, highlights how our interactions with colleagues significantly impact our behaviour, happiness, and departmental efficiency. Dysfunctional departments often correlate with poor personal relationships among consultants and senior nurses, ultimately affecting patient care.

Stefan's advice includes not taking unnecessary offence, showing gratitude, celebrating the good news, and fostering teamwork. While these may seem obvious, their implementation can transform workplace dynamics. Reflecting on Stefan's insights has prompted me to reevaluate my practices and strive for better interpersonal relationships at work.

Good workplace relationships are foundational to creating a supportive and effective healthcare environment. When colleagues communicate openly, show appreciation for each other’s efforts, and work collaboratively, it leads to higher job satisfaction, reduced stress, and ultimately better patient outcomes. Stefan’s post serves as a reminder that the human element of healthcare is just as important as the clinical skills we bring to our practice.

Ventilation During RSI: Revisiting Established Practices

Another significant post examines whether we should continue ventilation during rapid sequence intubation (RSI). Traditional teaching discouraged ventilation during the apnea period due to safety concerns. However, for critically ill patients with low oxygen saturation, not ventilating can lead to severe hypoxia.

A randomized control trial in the ED assessed the safety of ventilation during this period. The study found that patients who were ventilated during the apnea period had less oxygen desaturation without significant adverse effects. While the study's sample size is small, it supports our evolving practices and aligns with our experiences. However, it is crucial to critically assess the study's methodology and incorporate this knowledge cautiously into clinical practice.

This trial’s findings challenge the long-standing dogma of no ventilation during RSI, pushing us to rethink and potentially update our protocols. As emergency medicine evolves, we must remain flexible and willing to adapt our practices based on emerging evidence. Ensuring that our approaches are both safe and effective is paramount to improving patient outcomes.

The Role of Scribes in the ED: Efficiency and Quality Improvement

Chris Gray's post on the use of scribes in the ED follows a previous discussion on this topic. Scribes can save time and improve documentation quality, which is vital in a high-pressure environment. A randomized control trial demonstrated that scribes do save time, though the effect size was modest. The potential for better documentation quality is equally important, making scribes a valuable addition to emergency departments. We are keen to hear from anyone using scribes in the UK, as this practice is more common in the US.

The use of scribes can enhance the efficiency of emergency departments by allowing physicians to focus more on patient care rather than administrative tasks. Improved documentation can also lead to better patient tracking, follow-up, and overall care quality. As our healthcare systems become increasingly strained, innovations like scribes offer practical solutions to maintain high standards of care.

Reflecting on February: A Busy Month in Emergency Medicine

February was packed with insights and developments in emergency medicine. From international collaborations and trauma management advancements to revisiting PTSD recovery stories and philosophical reflections on workplace relationships, the month offered a wealth of knowledge. As we move into March, we look forward to sharing more exciting updates, including coverage of the SMACC conference.

The diversity of topics covered in February highlights the multifaceted nature of emergency medicine. Each paper and blog post contributes to a broader understanding of how we can improve patient care, support our colleagues, and adapt to new challenges. This continuous learning process is what makes emergency medicine such a dynamic and rewarding field.

Supporting the St Emlyn's Podcast: Your Contribution Matters

Since 2012, we've funded the blog and podcast out of our own pockets. As our audience grows, so do our expenses. If you find our content valuable and wish to support us, please consider making a small donation or subscribing regularly. Your contributions help us keep St Emlyn's a free, open-access medical education resource for all.

By supporting the St Emlyn's Podcast, you enable us to continue delivering high-quality, evidence-based content to the emergency medicine community. Your donations help cover the costs of hosting, producing, and distributing our materials, ensuring that we can reach a global audience of healthcare professionals.

Conclusion

The February edition of the St Emlyn's Podcast provided a rich tapestry of insights and developments in emergency medicine. From my journey to Jeddah and the fascinating trauma studies to the personal stories of PTSD recovery and the philosophical reflections on workplace relationships, there was something for everyone.

Our exploration of new research, such as the reevaluation of PE in syncope and the safety of ventilation during RSI, underscores the importance of staying informed and adaptable in our practice. Meanwhile, discussions on the role of scribes and the significance of workplace dynamics highlight the multifaceted challenges we face in emergency medicine.

As we look forward to March and beyond, we remain committed to bringing you the latest in emergency medicine and fostering a community of continuous learning and improvement. Thank you for joining us on this journey, and we appreciate your support in keeping St Emlyn's a vital resource for all.

Stay tuned for more insights, updates, and discussions. Until then, keep pushing the boundaries of emergency medicine, supporting your colleagues, and striving for excellence in patient care. Have a great time, and we’ll be back with you shortly.

Ep 128 - Can we use diagnostic probability to guide treatment thresholds in ACS with Charlie Reynard and Rick Body

In this episode of the St. Emlyn's podcast, Rick Body and Charlie Reynard discuss an influential research project conducted by Dr. Reynard during his academic foundation program. The paper, titled 'Optimizing Antiplatelet Utilization in the Acute Care Setting,' explores decision-making under clinical uncertainty, specifically in emergency medicine for suspected acute coronary syndromes (ACS). Through systematic reviews and decision tree modeling, the research evaluates the benefits and risks of various antiplatelet therapies, such as Ticagrelor and aspirin versus Clopidogrel and aspirin. The findings reveal that Ticagrelor and aspirin are often more beneficial for patients with a greater than 8% probability of ACS, while Clopidogrel holds little to no place in current practice. The discussion opened up new questions about dynamic risk prediction and the importance of modeling to inform clinical decisions.

00:00 Introduction to the Podcast

00:26 Charlie's Research Background

00:52 Overview of the Research Paper

01:17 Decision Making Under Uncertainty

03:05 Systematic Reviews and Data Collection

03:46 Building the Decision Tree Model

04:48 Results and Key Findings

08:07 Implications for Clinical Practice

09:19 Future Directions and Conclusion

Ep 126 - December 2018 Round Up

A Deep Dive into December: The Best of St. Emlyn’s Blog and Beyond

Welcome to the St. Emlyn’s Podcast! I’m Simon Carley, and today we’re going to journey through December 2018. This month has been filled with intriguing discussions, significant insights, and top-notch blogs from a variety of experts. As we wrap up the year and get ready to welcome 2019, it’s the perfect time to reflect on the key topics that have shaped our discussions around Christmas and the New Year.

Tribalism in Healthcare with Ross Fischer

First up, we have an insightful contribution from Ross Fischer, a key member of the St. Emlyn’s team and a Pediatric Surgeon based in Sheffield. Ross has delved into the topic of tribalism in healthcare, a subject we've explored previously but which remains ever relevant.

Tribalism refers to the formation of groups or 'tribes' based on common beliefs and cultures, which significantly influences our behaviour and treatment approaches in healthcare. Ross's blog revisits a remarkable presentation by Vic Brazil at SMACC Gold in 2014, highlighting how tribalism drives our interactions and behaviours within the medical field.

In healthcare, tribes often form around specialities – emergency physicians, surgeons, anaesthetists, etc. While having a strong group identity can be positive, it can also lead to unhealthy competition and misunderstandings. For example, emergency physicians might unfairly label surgeons as uncooperative, which is not only untrue but also counterproductive.

Ross's extensive experience across various medical cultures has given him a unique perspective on this issue. His blog emphasizes the importance of recognizing and mitigating tribalism to foster better cooperation and ultimately improve patient care. Some strategies he suggests include using personal names during referrals, face-to-face communication, being supportive rather than critical when things go wrong, organizing social events across specialities, and calling out tribalism in casual conversations.

Conservative Management of Chest Trauma

Next, I’ve put together a blog on the conservative management of chest trauma, inspired by several presentations I've done this year on torso trauma. The increasing body of evidence suggests that not all chest injuries, such as hemothoraces and small pneumothoraces, require invasive intervention.

Reflecting on my early days in emergency medicine, we operated under the strict guideline that any pneumothorax or hemothorax warranted a chest drain. However, advances in imaging technology, like whole-body CT scans, have revealed that many small pneumothoraces and hemothoraces were previously undetected and thus untreated without significant complications.

Recent studies, including a substantial observational study by Walker, support the safety of conservative management for many of these cases. This shift in practice aligns with our experiences here in Virchester, where we often opt to observe rather than immediately intervene with chest drains, even in ventilated patients. The evidence is still evolving, but it’s encouraging to see data supporting less invasive approaches.

Intensive Care Insights with Dan Horner

Dan Horner, Professor of Emergency Medicine at Virchester West, has shared three exceptional posts from our time at the Intensive Care Society conference in London. The interface between emergency medicine and ICU is a critical area, and Dan’s insights are invaluable for anyone interested in this field.

One standout topic from the conference was Tom Evans' presentation on exercise physiology. Though I missed it, the demonstration with Olympic rowers on stage, showcasing their lactate levels, was reportedly phenomenal. This type of hands-on demonstration highlights the extraordinary resilience and adaptability of human physiology, insights that are crucial for both emergency and intensive care practitioners.

In addition to exercise physiology, Dan and I covered the continuum of patient care from the roadside to critical care, emphasizing the importance of effective handovers and collaborative work with paramedics. Our discussions included the zero point survey, ATMIST handovers, and the significance of follow-ups to ensure paramedics receive feedback on their patients' outcomes, all crucial elements for improving patient care and professional practice.

FemInEM Conference Highlights with Natalie May

Natalie May wrapped up our review of the FemInEM conference, emphasizing the multifaceted nature of medicine. The themes of passion, role models, organization, consistency, persistence, mentorship, and leadership were central to the conference discussions. FIX19, the upcoming FemInEM event, promises to continue this tradition of exploring how medical professionals can impact not just clinical outcomes but also their own lives, colleagues, and the broader community.

HIV Management in Emergency Medicine

Gareth Roberts, a recent addition to our consultant team in Manchester, provided a comprehensive review of HIV management from an emergency physician’s perspective. His blog focuses on post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), critical areas for emergency physicians to master.

With the ongoing changes in HIV treatment and prevention, understanding the nuances of PEP and PrEP is vital. Gareth also touches on the rise of chemsex and its implications for emergency medicine, emphasizing the need for awareness and appropriate management strategies for patients involved in these practices.

Trauma Laparotomy: A Decade of Data

Rich Cardens explored the intriguing findings from his PhD research on trauma laparotomy. Despite significant advancements in trauma care over the past decade, the mortality rate for trauma laparotomy has remained unchanged. This surprising discovery prompts a deeper investigation into the factors influencing these outcomes.

Rich's research compares data from the JTTR military registry and the Royal London Hospital, highlighting the need for a comprehensive trauma emergency laparotomy audit. Understanding why mortality rates haven't improved could lead to better strategies and practices in trauma care.

Game of Thrones Mortality Study

For a lighter, yet still educational note, Janos Byan Beethar found an entertaining yet insightful study in the Injury Prevention Journal. This study analyzed the mortality of characters in Game of Thrones, a bit of fun that doubles as a critical appraisal exercise. With over half of the 330 characters meeting untimely deaths through injury, burns, or poisoning, the study offers a unique way to engage with epidemiological concepts and cause-effect associations.

Interestingly, the study also suggests that characters who change allegiances have a higher survival rate – perhaps a subtle hint at the importance of adaptability in both fictional and real-world scenarios.

Looking Ahead to 2019

As we close out December, it’s clear that 2018 has been a year of growth, learning, and exciting developments here at St. Emlyn’s. From addressing tribalism in healthcare to exploring conservative management strategies for chest trauma, and from the latest insights in intensive care to the evolving field of HIV management, our blogs have covered a wide range of critical topics.

We look forward to continuing this journey in 2019, bringing you the latest research, discussions, and insights in emergency medicine. Whether through our blogs, podcasts, or live events, we aim to foster a community of continuous learning and professional growth.

Stay connected with us on Twitter, Facebook, the blog, and the podcast. We’re here to support you in your practice and to ensure you stay at the forefront of emergency medicine. Here’s to another great year with St. Emlyn’s!

Ep 112 - Acute Psychiatric Emergencies in the ED.

 

The Importance of Acute Psychiatric Emergencies Training: Insights from the St Emlyn's Podcast

Introduction

Welcome to the St Emlyn's blog, where we delve into the latest topics and developments in emergency medicine. Today, we explore a crucial yet often overlooked aspect of our field: acute psychiatric emergencies. This post summarizes a recent conversation between Simon Carley and Kevin McRey Jones, highlighting the significance of addressing psychiatric emergencies within emergency departments. We will shed light on the Apex course, its methodologies, and the vital need for integrating psychiatric care into emergency medicine.

Addressing the Gap in Psychiatric Emergency Care

Kevin McRey Jones, a key figure in emergency medicine, recently joined the St Emlyn's podcast to discuss the Apex course, an initiative designed to fill a significant gap in emergency medicine training. Despite considerable advancements in managing various medical emergencies, psychiatric emergencies often remain underemphasized.

The Apex course addresses this gap by focusing specifically on acute psychiatric emergencies. Kevin explained that while many advancements have been made in managing cardiac, trauma, and obstetric emergencies, psychiatry has not received the same systematic approach. This has led to a fragmented care model where physical and psychological components are often treated separately.

The Origins and Purpose of the Apex Course

The Apex course, originating in 1992 with the Advanced Life Support Group, was created to systematize the training for managing acute psychiatric emergencies. Kevin, who has a long history of organizing and delivering courses in emergency medicine, emphasized the need for a unified approach to patient care. The course aims to bridge the gap between emergency physicians and psychiatrists, promoting a co-ownership model of patient management.

Why Psychiatric Emergencies are Often Overlooked

One major reason psychiatric emergencies have not received the same attention as other medical emergencies is the perception that these are problems best handled by psychiatrists or liaison nurses. This mindset leads to a tendency to pass psychiatric cases off to specialists rather than integrating psychiatric care into the emergency department's responsibilities.

Kevin highlighted a common issue where patients with both physical and psychological illnesses are often divided into two separate cases: the physical bit managed by emergency physicians and the psychological bit by psychiatrists. This division can lead to suboptimal care and poor outcomes, as the interconnected nature of these issues is overlooked.

The Consequences of Ignoring Psychiatric Components

Ignoring the psychiatric component of patient care can have severe consequences. Kevin pointed out that patients with psychiatric diseases often have poor outcomes regarding their physical health. This is largely because their physical ailments can be neglected due to the focus on their psychological issues.

Simon added that the outcomes for patients with psychiatric diseases, in terms of their physical health, are often terrible. This emphasizes the need for a more integrated approach to patient care, where both physical and psychological aspects are managed simultaneously.

The Need for Integrated Care

Kevin stressed the importance of co-owning the problem rather than treating psychiatric emergencies as the sole responsibility of psychiatrists. By doing so, emergency departments can provide more comprehensive care, addressing both physical and psychological needs. This integrated approach is essential for improving patient outcomes and ensuring that all aspects of a patient's health are considered.

Common Practices and Their Pitfalls

Simon discussed a common practice in emergency departments where patients presenting with apparent psychiatric problems are often assessed solely for physical issues before being referred to psychiatric specialists. This "clear them medically" approach can lead to delays in psychiatric care and inadequate management of the patient's overall condition.

Kevin acknowledged this issue and emphasized the need for emergency physicians to be involved in the psychiatric assessment and management of these patients. This approach ensures that all aspects of the patient's health are addressed, leading to better outcomes.

Rethinking Emergency Care for Psychiatric Patients

Simon reflected on the current practices and highlighted the need for change. The idea of dividing patient care into physical and psychological components, with little overlap, is increasingly seen as problematic. Kevin agreed, noting that sometimes organic problems can be overlooked when patients are quickly referred to psychiatric care without a thorough assessment.

The Apex Approach: AIOU Methodology

The Apex course introduces the AIOU methodology, designed to integrate psychiatric and medical care seamlessly. This structured approach includes:

• A: Assessment of aggression and agitation.
• E: Environment in which the patient is assessed.
• I: Intent of the patient, including suicidal ideation or harm to others.
• O: Objects the patient may use to carry out their intent.
• U: Unified assessment, combining both physical and psychological evaluations.

Implementing the AIOU Methodology

Kevin explained that the AIOU methodology is a co-created approach by psychiatrists and emergency physicians. This collaboration ensures that both physical and psychological aspects of patient care are addressed. The methodology aligns with the primary assessment, resuscitation, and definitive care phases familiar to emergency physicians.

Addressing Challenges in Psychiatric Emergency Care

Rapid tranquilization is a common concern in managing psychiatric emergencies. Kevin emphasized that the goal is to use the minimum level of intervention required, whether that involves oral medication or, if necessary, safe rapid tranquilization. The course teaches a balanced approach to ensure patient safety and effective management.

The Role of Risk Assessment

Psychiatry is a risk-driven specialty, focusing on assessing risks of violence, flight, and harm to self and others. Kevin highlighted the importance of minimizing these risks through a structured, systematic approach. This methodology allows for a comprehensive evaluation and management plan that addresses both immediate and long-term risks.

Structured Approach to Both Psychiatric and Physical Assessment

The Apex course emphasizes a structured approach to both psychiatric and physical assessments. This dual-focus ensures that all aspects of a patient's health are considered, leading to more comprehensive and effective care.

Collaboration Between Psychiatrists and Emergency Physicians

The course promotes collaboration between psychiatrists and emergency physicians, encouraging them to learn from each other and develop joint solutions to patient care challenges. This partnership is essential for providing holistic care and improving patient outcomes.

Co-Assessment and Risk Management

The course highlights the importance of co-assessment and risk management. By working together, psychiatrists and emergency physicians can provide a more unified approach to patient care, addressing both physical and psychological needs simultaneously.

Substance Abuse and Psychiatric Symptoms

Substance abuse often complicates psychiatric emergencies. The Apex course takes a symptom-based approach, focusing on the specific challenges presented by patients with delirium, confusion, aggression, and self-harm. This approach allows for a more tailored and effective management plan.

Prevalence and Importance of Addressing Psychiatric Emergencies

Psychiatric emergencies are more common than many realize. Kevin noted that about 5% of patients in emergency departments present with direct psychological or psychiatric symptoms. Including substance abuse and alcohol-related cases, this number can rise significantly. Addressing these emergencies systematically is crucial for improving patient care and outcomes.

Conclusion

The Apex course represents a significant advancement in the training and management of acute psychiatric emergencies. By promoting a unified approach to patient care, it addresses a critical gap in emergency medicine. Collaboration between psychiatrists and emergency physicians is essential for providing comprehensive care and improving patient outcomes. For more information on the Apex course and upcoming training sessions, visit the Advanced Life Support Group's website.

Final Thoughts

Reflecting on the discussion, Simon emphasized the importance of integrating psychiatric care into emergency medicine. The dichotomy approach, where physical and psychological issues are treated separately, is increasingly seen as inadequate. The Apex course offers a pathway to more comprehensive, patient-focused care, ensuring that all aspects of a patient's health are addressed.

How to Learn More

For those interested in learning more about the Apex course and upcoming training sessions, visit the Advanced Life Support Group's website at www.alsg.org. The course is offered in various locations, providing opportunities for emergency physicians and psychiatrists to enhance their skills and knowledge in managing acute psychiatric emergencies.

By embracing this integrated approach, we can ensure that patients receive the comprehensive care they need, improving outcomes and advancing the field of emergency medicine.

Ep 99 - October 2017 Round Up

Navigating the Landscape of Emergency Medicine: Insights from St. Emlyn's

Welcome to St. Emlyn's, your go-to resource for the latest in emergency medicine. Our recent discussions cover a range of topics, from evolving communication strategies in major incidents to the nuances of managing chronic health issues among healthcare professionals. Let's dive into key insights and updates from our blog and the recent College of Emergency Medicine conference.

Modernizing Major Incident Communication

Traditionally, emergency departments relied on landlines and telephone trees for major incident alerts. However, modern digital tools like WhatsApp, Facebook, and Twitter offer more efficient solutions. Inspired by incidents like the Manchester bombing, our recent blog post details how to set up a robust communication system using WhatsApp. This involves configuring specific alert tones and ensuring confidentiality, providing a quick and reliable way to mobilize staff during crises.

Clots and Immobilization: Current Research and Practices

Clot management, especially in the context of immobilization, remains a critical area of study. Dan Horner's work, including the Tilly study, explores whether prophylactic low molecular weight heparins should be used for patients with injuries like Achilles tendon ruptures. Current guidelines suggest a nuanced approach, advocating for patient-specific discussions based on individual risk factors for DVT. This research highlights the importance of personalized treatment and continuous guideline updates.

The Role of Ultrasound in Managing Superficial Vein Thrombosis

The management of superficial vein thrombosis (SVT) has been another focus. Using ultrasound, as Dan Horner suggests, can help assess the extent of SVTs and determine the need for anticoagulation, particularly when SVTs are near the saphenofemoral junction. This approach ensures comprehensive care and prevents complications from missed DVT diagnoses.

Global Perspectives: Insights from South Africa

Our collaboration with UK physicians working in South Africa provides a global perspective on emergency medicine. Despite resource limitations, the dedication to delivering quality care remains consistent across continents. This exchange of knowledge reinforces the universal principles of emergency medicine, emphasizing adaptability and resourcefulness.

Addressing Chronic Health Conditions in the Workplace

A guest post by Harriet, a Manchester-based emergency physician with rheumatoid arthritis, offers insights into managing chronic health issues while working in emergency medicine. Harriet's story highlights the physical demands of the job and the need for supportive workplace practices. It encourages a more inclusive approach, ensuring that all healthcare professionals can perform at their best, regardless of health challenges.

Re-Evaluating Oxygen Therapy in Acute Coronary Syndromes

Evidence-based medicine is at the heart of St. Emlyn's, and the DETO2X-AMI study has sparked significant discussion. This study suggests that supplemental oxygen may not always benefit patients with acute coronary syndromes, particularly those with normal oxygen saturation levels. This finding prompts a more tailored approach to patient care, aligning treatments with the latest evidence.

The Emergence of New Cardiac Biomarkers

Cardiac myosin-binding protein C has emerged as a promising new marker for early myocardial infarction diagnosis. However, Rick Body cautions that despite its potential, the transition from research to clinical practice involves numerous hurdles. The practical application of new biomarkers requires rigorous testing and regulatory approval.

Revisiting Tetanus Management

Chris Gray's exploration of tetanus management emphasizes the need for accurate administration of vaccinations and immunoglobulin. Despite being a well-known disease, misunderstandings about treatment protocols persist. Chris's post clarifies who needs boosters and who requires immunoglobulin, ensuring patients receive appropriate care.

Lessons from Mass Casualty Incidents

Zafira Kasim’s insights from the AAST meeting highlight critical lessons from mass casualty incidents like the Florida nightclub shooting and the Boston bombings. These experiences underline the importance of preparedness and the continuous updating of major incident protocols. The blog post provides practical strategies for refining emergency response plans.

The State of Emergency Medicine in the UK

The recent College of Emergency Medicine conference in Liverpool provided a comprehensive overview of the state of the specialty in the UK. Despite challenges like burnout and systemic pressures, the conference showcased a resilient and dedicated community. Presentations highlighted the importance of mental health, resilience, and compassion in maintaining quality care. Caroline Leach’s discussion on compassion underscored the emotional journey of healthcare professionals and the need for empathy in the workplace.

The Need for More Academic Involvement

The conference also stressed the importance of increasing academic involvement in emergency medicine. The UK currently has a low number of emergency medicine professors compared to other specialties. There is a strong call to foster the next generation of academic leaders, with initiatives like new NIH positions offering opportunities for growth.

Preparing for Winter: The Upcoming Challenges

As winter approaches, emergency departments anticipate increased patient volumes and complexity. At St. Emlyn's, we emphasize resilience and preparedness, supporting healthcare professionals through these demanding times. Our aim is to provide resources and knowledge to enhance patient care and professional satisfaction.

Looking Ahead: Embracing Innovation and Community

St. Emlyn's remains committed to keeping you informed and passionate about emergency medicine. Our upcoming podcast project will further engage and update you on the latest developments. We encourage you to explore our blog for the most recent posts, research findings, and expert opinions.

In conclusion, the field of emergency medicine is both challenging and rewarding. At St. Emlyn's, we are proud to contribute to this dynamic community, supporting the ongoing professional development of our colleagues. As we navigate the complexities of modern healthcare, we remain dedicated to providing the best possible care for our patients and ensuring the well-being of our medical community. Stay connected with us for continuous updates and insights into the ever-evolving world of emergency medicine.

Ep 96 - Everybody's free - Top Tips for the Class of 2017

Key Advice for Medical Professionals in Emergency Medicine

Navigating daily challenges in the demanding field of emergency medicine requires a blend of technical skills, emotional intelligence, and personal well-being. Drawing from the wisdom shared with the Class of 2017, here’s a comprehensive summary of essential advice for healthcare professionals in emergency settings.

1. Prioritize Sleep

Among the many pieces of advice, the most crucial is the emphasis on sleep. Scientific research underscores the importance of adequate rest for cognitive function and overall health. For medical professionals, sufficient sleep is vital for maintaining alertness and making sound decisions, both of which are critical in high-pressure environments like emergency departments.

2. Bring Your Best Self to Work

Each day, strive to be the best version of yourself when you come to work. However, it’s important to recognize that everyone has off days. If you’re struggling, communicate with a senior colleague. They understand the pressures of the job and can offer support. Practising kindness towards yourself, patients, and colleagues fosters a positive work environment and enhances patient care.

3. Role Model Exemplary Behavior

Your conduct in the workplace sets a standard for others. Newer staff and peers observe and learn from your actions. Therefore, it’s essential to lead by example and exhibit a professional behaviour that you would want others to emulate. This principle helps maintain high standards of care and professionalism within the department.

4. Maintain a Balanced Diet and Hydrate

The fast-paced nature of emergency medicine makes it tempting to overlook proper nutrition. However, maintaining a balanced diet and staying hydrated is crucial. Avoid fad diets and focus on eating nutritious meals and drinking plenty of fluids. Regular breaks are not just a right but a necessity for recharging and sustaining your energy levels throughout the shift.

5. The Impact of a Smile

Emotional contagion—the phenomenon where emotions are transferred from one person to another—plays a significant role in healthcare settings. A simple smile can positively influence the emotional climate of the department. By maintaining a positive demeanour, you can uplift the morale of both your colleagues and patients, contributing to a more supportive environment.

6. Effective Communication

Clear communication is fundamental in emergency medicine. Always introduce yourself to patients and colleagues with a clear “Hello, my name is...” During patient assessments, address three key questions:

1. Does the patient need resuscitation?
2. Does the patient need pain relief?
3. Will the patient require further care as an inpatient?

These questions help prioritize and guide the patient’s treatment plan effectively.

7. Administer Pain Relief Promptly

When patients present with pain, provide analgesia early in their care. This step should precede a detailed history and examination. Addressing pain promptly not only improves patient comfort but also establishes a foundation for a more comprehensive evaluation.

8. Develop Differential Diagnoses

In emergency medicine, formulating differential diagnoses is crucial. Consider at least three possibilities for each case, such as pulmonary embolism (PE), aortic dissection, or sepsis. Understanding the range of potential diagnoses helps guide your treatment decisions. It’s important to remember that diagnostic challenges are part of the job, and outcomes may vary based on the limited information available.

9. Understand Patient Needs

Engage with patients to understand their expectations and needs. Knowing what patients hope to achieve from their visit helps tailor your approach and makes their experience more manageable. Always seek to improve their day, even if your own is challenging. Empathy and understanding are key to providing compassionate care.

10. Embrace Teamwork

Emergency medicine relies heavily on teamwork. You’ll frequently undertake tasks that extend beyond your specific role, such as checking vital signs, transporting patients, or administering medications. Embrace these tasks as part of a collective effort to enhance patient care. Teamwork ensures that all aspects of patient care are covered and supports a cohesive work environment.

11. Plan and Communicate

Before discussing a patient case with a senior, develop your own plan. Present your questions and concerns early rather than waiting for investigations. Effective decision-making often relies on history and examination, so keeping your senior and nursing team updated with your plan is essential. This approach facilitates timely and informed decision-making.

12. Learn and Seek Advice

Aim to learn three new things each day. Your senior colleagues possess a wealth of experience and knowledge. Don’t hesitate to ask questions and seek their advice. Their insights can help you navigate complex cases and improve your practice. As a fresh perspective, your observations and suggestions for improvement are valuable.

13. Find Joy in Your Work

Despite the inherent challenges of emergency medicine, find joy in your role. Being part of patients’ lives during their moments of crisis is a profound privilege. Maintain a positive outlook and remember that your work, though demanding, makes a significant difference in people’s lives. And always ensure you get enough sleep to perform at your best.

Conclusion

Navigating the world of emergency medicine requires balancing personal well-being, professional behavior, and effective patient care. By prioritizing sleep, maintaining a balanced diet, practicing kindness, and embracing teamwork, you can enhance your performance and job satisfaction. Clear communication, prompt pain management, and ongoing learning are essential components of providing high-quality care. Above all, remember the privilege of being part of patients' lives during critical moments and strive to make a positive impact every day.

Ep 89 - March 2017 Round Up

In a new podcast format Simon (@EMManchester) and Iain (@docib) discuss the month's offerings from the St Emlyn's blog and podcast (www.stemlynsblog.org).

 

It's been a month full of interesting posts on subjects as diverse as Thrombolysis in Stroke (Alan Grayson), The Future of Emergency Medicine in the Social Age (Simon), Cardiac Arrest Centres (Simon), Love in Critical Care (Liz Crowe), Transfers (Nat and Simon), Thrombolysis in PE (a guest post from FOAMed legend Anand Swarminathan) and Benzos in Back Pain (Janos). Head to the website for the articles themselves and all the references and links you need.

 

We're aiminig to make this a regular monthly podcast - let us know if it's useful and enjoyable and how we could make it even more educational.

Ep 57 - When things go wrong - the difficult conversation

Simon and Nat talk about how to have that tricky conversation when you have to tell a colleague that they may have made a mistake.

vb

S

Ep 54 - Intro to EM: Analgesia in the ED.

Iain and Simon discuss the core skills that all EM clinicians need to manage pain in the ED.

These are the basics, but don't be put off. The basics are more important than the fancy stuff that we will discuss in a later podcast.

vb

S

Ep 35 - New (or are they really new) Oral Anticoagulants and the Emergency Physician PART 1

Rick Body and Kerstin de Wit discuss the role of NOACs in clinical management. Part 1 addresses the basics, stuff you should know if you are prescribing these drugs.

Part 1 tells us the good stuff, don't forget to listen to 2 and 3 in the next few weeks as not everything is perfect ;-)

Check out the BLOG POST HERE
vb

R