The latest blog posts, ideas and thoughts from the St Emlyn's podcast. This month with Simon Carley and Rick Body,
This is a really important concept developed by Charlie Reynard and Rick Body here in Manchester. There is an accompanying paper in the EMJ that you can read via this link https://emj.bmj.com/content/34/12/A870
This concept could radically change how we make probabilistic prescribing decisions in the ED. Have a listen and look out for a blog post on St Emlyn's soon.
This is the monthly round up of blogs from the St Emlyn's team
Tribalism with Ross Fisher https://www.stemlynsblog.org/breaking-down-tribalism-onetribeemta-st-emlyns/
Conservative management of chest trauma https://www.stemlynsblog.org/jc-conservative-management-of-chest-trauma-st-emlyns/
ICS SOA day 1 https://www.stemlynsblog.org/st-emlyns-on-tour-icssoa2018/
Handover principles https://www.stemlynsblog.org/handover-process-practice-and-controversy-icssoa2018-st-emlyns/
ICS SOA day 2 https://www.stemlynsblog.org/icssoa2018-day-2-st-emlyns-on-tour/
ICS SOA day 3 https://www.stemlynsblog.org/icssoa2018-day-3-st-emlyns-on-tour/
FeminEM part 4 https://www.stemlynsblog.org/fix18-part-four/
PEP, PEPSE and HIV https://www.stemlynsblog.org/pep-prep-and-all-things-hiv-st-emlyns/
Game of Thrones https://www.stemlynsblog.org/ste-journal-club-a-christmas-games-of-thrones-issue/
November was a busy month for the St Emlyn's team with a variety of blogs on conferences, EBM, philosophy and education. Here's the podcast and the links to the blogs mentioned in November.
This podcast was recorded at the Intensive Care Society State of the Art meeting in London 2018. Simon Carley interviews Prof Peter Brindley on the interface of technology, humans and humanity in critical care. The audio was recorded live and at the venue so there is a fair bit of background noise, but we hope that this does not distract from a wide ranging and fascinating podcast.
Five strategies to improve your resuscitations.
1. Zero point survey
2. Peer review
3. 10 in 10
4. Hot debriefs
5. Fly the patient
You can read about these strategies, watch the video and learn about the background on the St Emlyn's blog here https://www.stemlynsblog.org/stemlynslive-five-free-strategies-to-improve-your-resuscitation-practice-st-emlyns/
Salim Rezaie from the REBEL EM podcast takes us through the optimal management of cardiac arrest and also explores some of the controversies and difficulties that make the difference to our patients.
You can read a lot more about the background to this talk, see the evidence and watch the video on the St Emlyn's site. Just follow this link. https://www.stemlynsblog.org/beyond-acls-salim-rezaie-at-stemlynslive/
Here's our round up of the best of the blog from September 2018.
The following blogs are discussed.
OOHCA and airway management. Do we need a tube? http://www.stemlynsblog.org/jc-oohca-and-airway-management-do-we-need-a-tube-st-emlyns/
The Zero Point Survey. Optimising resuscitation teams in the ED. https://www.stemlynsblog.org/jc-the-zero-point-survey-optimising-resuscitation-teams-in-the-ed-st-emlyns/
Subacute and massive PE management https://www.stemlynsblog.org/we-call-it-massiiiiiiivve-pe-at-st-emlyns/
EMS Gathering and podcast https://www.stemlynsblog.org/ems-gathering-review-and-podcast-st-emlyns/
ResusTO: A simulation/resuscitation conference like no other https://www.stemlynsblog.org/resusto-a-simulation-resuscitation-conference-like-no-other/
Monkeypox has arrived https://www.stemlynsblog.org/monkeypox-has-arrived-is-the-panic-justified-st-emlyns/
Micro Machines: Sick neonates at RATH18 https://www.stemlynsblog.org/micromachines/
Equality and Diversity in EM. What I learned as a recovering racist. https://www.stemlynsblog.org/equality-and-global-health-what-i-learned-from-being-a-recovering-racist/
StEmlyn's at EusEM (Four posts)
Nat and Simon discuss the recent #badEMfest18 conference.
You can read more about the conference on our posts on the stemlynsblog website.
Day 4... it's coming
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This month we have a podcast on how we approach patients with mental health needs in the ED. It outlines the rationale and delivery of a change in how we manage some of the most vulnerable patients in the ED. We hope you find it interesting and I suspect you will also find it quite challenging. We are aiming to improve the care of patients with Mental Health needs, but in doing so we must face our own prejudices and practices, which are not always healthy.
Editorial note on language – as you listen to the podcast you might be surprised to hear us use words like ‘insane’ in relation to decisions and systems. In some ways it seems incongruous to use such terms in a podcast that promotes a better understanding of mental health issues. We considered taking them out, but after consideration we left them in an attempt to illustrate the false dichotomy between medical and psychiatric needs that is embedded in much of our work. Perhaps the use of language reflects this and makes the point that we can do better.
Why do we need to rethink our approach to Psychiatric emergencies in the ED?
There are a group of life threatening conditions that present to your ED that you don’t deal with, or at least you don’t deal with very well. This group of conditions has a significant mortality and an incredibly high morbidity, but if you are a typical emergency physician you probably don’t think you own the problem. This group of conditions is at least as common as chest pain and yet it’s unlikely that you feel the same level of ownership of the problem.
The issue is of course that of psychiatric illness. In Virchester it accounts for about 1 in 20 patients through the door, and that number is much, much higher if we were to include substance abuse and its related outcomes.
In general, the approach in many UK units is to divide the patient up on arrival into physical and mental health needs. We feel responsible for the physical problem and then we try and offload any psychiatric problems onto the psychiatrists and mental health teams. At the centre of this is the patient who really does not see or feel this dichotomy and we really need to challenge our approach to this.
Such dichotomies are embedded in our systems. I’m sure that many readers will be familiar with the request to ‘medically clear’ a patient in order that they can then be assessed by the mental health team. Bizareer customs and practice take place around these assessments, for example in Virchester the rule that a patient with a heart rate of more than 100 cannot be medically fit for assessment is sometimes used to decline psychiatric assessment. Such informal rules (none are actually written down or appear in any agreed protocol) result in delayed assessments, patient distress and long waits in the ED. I could go on, and whilst there is good and practice amongst all teams and specialities (we are just as bad at the mental health teams in promoting this dichotomy), the point is that we really don’t act in the patient’s best interests by dividing mental and physical health.
This clear difficulty was one of the starting points for the APEX course, which aims to bring psychiatry and emergency medicine together for the benefit of patients, services and staff.
The interview on the podcast is recorded with Prof. Kevin Mackway-Jones who many of you will know through his work with the Advanced Life Support Group. He was the instigator of APLS at a time when there was a clear need for emergency physicians to improve their approach and knowledge of paediatric emergencies. APEx feels the same. A common condition in our EDs for which we are not currently doing the best that we can for our patients and where a joint teaching and learning approach is needed between the ‘tribes’ of medicine.
This could be a game changer to how we manage a very common and very vulnerable group of patients in the ED.
So what’s on the course?
I can’t give you the whole courses here but there are a few principles that underpin the content and approach.
Key points.
Find out more
You can find out more on the ALSG website here.
What has APEx got to do with St Emlyn’s?
At St Emlyn’s we are letting you know about the course for several reasons. Many of us teach and support the work of the ALSG charity (for free and because we believe in it), but also that we all believe that the care of patients with mental health needs can be improved. They are a vulnerable group who generally get a bad deal when they present in crisis to emergency departments. We know we can do better and we believe that this course will help us achieve our goal to do the best that we can for our patients.
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Simon and Iain talk through what the team has been up to in April. All the blogs should be on the website and of course you can subscribe to the podcast via iTunes or via PodBean.
Key publications in April.
1. Our e-book on health and wellbeing for the resuscitationist. http://stemlynsblog.org/the-resuscitationists-guide-to-health-and-wellbeing-a-st-emlyns-e-book/
2. Police drop offs for penetrating trauma in the US. http://stemlynsblog.org/to-protect-and-serveand-drop-off-st-emlyns/
3. The latest blogs on the amazing #badEMfest18 conference in South Africa http://stemlynsblog.org/bademfest18-day-3-st-emlyns/
4. The top 10 trauma papers of the year http://stemlynsblog.org/top-10-trauma-papers-2017-2018-for-traumacareuk-conference-st-emlyns/
5. Complications of anticoagulation http://stemlynsblog.org/complications-of-anticoagulation-and-how-to-manage-them-st-emlyns/
6. Trauma CT in kids http://stemlynsblog.org/jc-trauma-paediatric-wbct/
7. The folly of dichotomous diagnosis http://stemlynsblog.org/50-shades-black-white-folly-dichotomy/
8. Bonded in Blood with Ashley Liebig and Noah Gallagher http://stemlynsblog.org/bonded-in-blood/
9. How to coach your team and the Austrian EM conference http://stemlynsblog.org/how-to-coach-feedback-team-st-emlyns/
Gosh, when you write it down and think about all the work the rest of the team puts in to teach and learn it makes me kind of proud. Don't forget to join us later this year for the live version at #stemlyneLIVE in Manchester.
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Our last podcast from the teaching course in Copenhagen #dasTTC. George Wills, Simon Carley, Natalie May, Jesse Spurr and Salim Rezzaie give the faculty perspective.
The short version is we think and hope that the delegates learned something, but as a faculty we once again learned loads and met some amazing people.
Roll on the next course. (hint they are in San Fransisco and Melbourne).
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Chris Nickson, Natalie May and Simon Carley discuss simulation and educational theory on day 2 of the teaching course.
A quick round up of events from the excellent Teaching Course in New York (https://flippingmeded.com/) with guests Ross Fisher (@ffoliet), Ashley Leibig (@ashleyliebig), Sandra Viggers (@StarSkaterDK) and Camilla Sorenson (@Camillabirgitte).
For brilliant summaries of each day, with details from every talk, visit http://scanfoam.org/teaching-course-nyc-day-1-ttcnyc16/ (Day 1) and http://scanfoam.org/teaching-course-nyc-day-2-ttcnyc16/ (Day 2)
Simon and Iain chat about the first few days at EuSEM in Vienna. Some of the clinical and social highlights. We also have a bonus podcast at the end recorded with a volunteer at Iain's "Podcasting for Beginners'" talk. For more from EuSEM (The European Society for Emergency Medicine) congress follow the #eusem16 hashtag on Twitter.
Our series on critical appraisal nuggets in 5-10 mins. This week it's Randomisation. Great if you are revising for an exam in critical appraisal (e.g. FRCEM).
Sandra Viggers and Vic Brazil grace St.Emlyn's with a conference report from Sand Diego and the
International Meeting for Simulation in Healthcare (IMSH) #IMSH2016.
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.
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Liz Crowe joins Iain Beardsell to discuss really difficult conversations in the ED. How do we communicate terrible news in the ED and critical care.
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First of our podcasts from the London Trauma Conference.
A fantastic episode with Iain talking to Gareth Davies (from London HEMS) talking about Impact Brain Apnoea.
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A Christmas review of the world of EM, CC and resuscitation #FOAMed.
This review is no way exclusive and focuses on sites that people may not be familiar with. Take it as read that EMCRIT, LITFL, PHARM, ICN, SGEM, EMLitofNote, ALiEM, Resus.me, KI docs, etc. are already known to be awesome. Check them out and follow the many excellent #FOAMed sites around the world.
Check out the big hitters here http://www.aliem.com/social-media-index/
There are also so many other sites that we have not mentioned, but which we regularly visit and listen to.
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Next week Iain and Nat will be in London for the best trauma conference in the world. Join them in person, online, on the podcast and on twitter.
Check out the program here, it's amazing.
http://www.londontraumaconference.com/
Have fun 
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The Challenge and Value of Research in Emergency Medicine: at DGINA 2014
Rick Body's talk from DGINA on the need for research in EM.
Check out the associated blog post at http://stemlynsblog.org
Iain and Simon talk through the practicalities of in situ sim in the ED. How do we make it happen in a way that works and helps individuals, teams and departments learn together.
