A critical appraisal nuggest on simple ways to understand the true effect of an intervention. Also see this more in depth podcast done with Iain Beardsell
A critical appraisal nuggest on simple ways to understand the true effect of an intervention. Also see this more in depth podcast done with Iain Beardsell
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.
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)
Part 2 of our podcasts on major trauma handovers. This follows on from the discussion at SMACC and is intended to operationalise the concepts we talked about then. This is aimed at a UK audience but should apply pretty much anywhere. So hands off, eyes open and listen in, here we go.
Whilst we were in Dublin at the SMACC conference we took the opportunity to get some great minds together on the subject of ED handover at the point between prehospital and hospital teams for the critically ill or injured patient in the resus room.
This is an area of some difficulty in many areas (prob shouldn't be, but it is) and we thought it would be fun and useful to get perspectives from both sides.
As ever, we are not here to be definitive and your service may have a fantastic model that works well. This podcast is to help you think about what you're doing and to consider whether it can be improved.
Doug Lynch is a retrieval doctor from Australia
Ashley Voss-Liebig is a flight nurse from Texas
Natalie May is a retrieval doctor from Sydney (Virchester Alumnus)
Rusty Carroll is a senior paramedic from Virchester and a great supporter of the ATACC group.
We don't have all the answers, but we do have the ideas.
In Virchester it can certainly be improved.....
Tell us what you think and keep an eye out for the blog post on the same subject coming soon.
The James Lind Alliance is working with the public and the Royal College of Emergency Medicine on an incredibly important research priority setting exercise. This podcast with Rick and Simon explains why and how you must get involved (please).
Blog post here http://stemlynsblog.org/john-lind-alliance-update-st-emlyns/
As has become our pre-Christmas custom, Iain and I have been hanging out at the fabulous London Trauma Conference, hearing about advances and controversies in trauma care and tracking down some of the speakers to find out exactly what they really think (and recording it, for podcasts we'll release in due course).
The conference extends over four days, incorporating the Air Ambulance and Prehospital Day and the Cardiac Arrest Symposium; unfortunately we can't stick around for those but our colleagues over at the RCEM FOAM network will be podcasting from those days too, so keep an eye on their site and podcast feed too.
My talk from the RCEM conference in Manchester 2015.
Linked blog post here. http://stemlynsblog.org/making-good-decisions-in-the-ed-rcem15/
Have fun and enjoy your emergency medicine.
Another induction podcast on a common condition in the ED. Back pain in the ED - it's not all musculoskeletal and there are some really risky diagnoses out there that you need to think about.
Don't forget to listen to Iain's talk on chronic pain link here. https://vimeo.com/97811644
Red flag symptoms and analgesia advice below.
Interested in taking part in the SMACC Run? Visit http://wp.me/p2DMH0-6uX for everything you need to know or visit www.bit.do/smaccrun and complete the online form. Don't forget to pre-order your SMACC merchandise!
A short podcast updating the UK Advanced Paediatric Life Support (APLS) course guidelines for the management of trauma in children.
Don't forget to read the blog post here. APLS Updates: New kids on the block,
Great stuff, controversial in places, challenging to adult dogma and always excellent.
PS. If you ever get to hear him speak.... then do, he's awesome. Check this out.
Do you think you're awesome at assessing shock?
The stupendous Prof Tim Harris (who St.Emlyn's loves) tells us that all is not quite as it seems.....
Listen, learn, be awesome.
The number of patients seen in each ED with problems relating to early pregnancy in the UK is very variable - some hospitals have rapid referral pathways for patients who know they are pregnant. It's still worth thinking about early pregnancy problems though as all EDs see young women and many of these may not yet know that they are pregnant.
Our induction podcast covers our approach to women presenting to the ED
Nat and Iain
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.
Iain and Simon discuss the dilemmas of dealing with the patient presenting with chest pain to the ED.
Iain and Simon talk about the upcoming SMACC conference in Chicago and do their very best to persuade you to come to the best conference in the world
Simon and Iain discuss what might appear to be a rather dull subject, but it's not. Coding is a key to developing your department and also to secure the functions of UK emergency departments.
A great primer for everyone coming up to FCEM and to anyone interested in how Emergency Departments are funded in the UK.
Follow this link to the associated blog post http://stemlynsblog.org/show-money/
Vic Brazil of #FOAMed and #SMACC fame came to talk to the St.Emlyn's team in Virchester.
Listen in for top tips on looking great and sounding super.
John Hell is a Neurointensivist at University Hospital Southampton and very kindly gave up an afternoon to record his thoughts and share his considerable wisdom about Diffuse Axonal Injury.
I also managed to get him to discuss some other topics including the choice of induction agents and intravenous fluids in patients with head injury.
Please listen, enjoy and comment. We'd love to hear from you, and don't forget to visit the blog site for additional information, slides and content.
Recently we published part one of our series on cardiac troponins. If you haven't checked it out yet, you can find it here. In the second part, we're going to take a look at high sensitivity troponins and some of the more advanced areas around understanding cardiac troponin and its use in practice. We'll give you a quick run down on the troponin lingo - the language you need to be able to speak in order to fully understand how to use high sensitivity troponin in your practice, including terms like the limit of blank, limit of detection, co-efficient of variation and 99th percentile.
We'll also ask whether Joe Lex had a point when he stirred up controversy around these assays with this legendary tweet:
What if we called it "low specificity troponin" instead of "high sensitivity troponin?" Would that knock some sense into people?
— Joe Lex (@JoeLex5) October 9, 2012
So, check out the associated BLOG POST here and listen to the podcast. There is more on diagnostics and troponin to come very soon.
Hope you enjoy! Please keep the feedback, questions and comments coming. As always, we'd love to hear from you.
DOI: Much of my research work involves HsT. To help with this I have received reagents from companies who make HsT assays, but I not received any other financial benefit or gifts in kind as part of my work and have no financial ties to any companies.
Do you remember when it took three days to 'rule in' or 'rule out' an acute myocardial infarction (AMI)? When I was a medical student doing my first clinical attachments, I remember doing ward rounds on the CCU seeing patients with suspected AMI. The way they were managed is a million miles from what we do now. Back then, patients would have serial ECGs and then be admitted for cardiac enzyme evaluation over the course of the next 3 days. We'd measure CK, AST and LDH. 'CK' was the so-called 'early marker', which would rise early after the start of an AMI. Today we use CK as a marker of skeletal muscle damage (e.g. rhabdomyolysis). AST and LDH (today we think of these as liver function tests, I know) were the 'late markers' - and by late I really mean late - we might see a rise on days 2 and 3.
Could you imagine for a second, in today's world, ruling out AMI because their CK and LFTs were normal? It's completely unthinkable. That's how much cardiac troponin has changed our practice. We rely on it so completely to diagnose AMI. And yet, it's one of the most misunderstood tests in medicine. Given how much we use it, I guess we feel that we all should know lots about this test. But doctors still have so many questions. Here are just a few:
This is just a brief list. With the research I do in this area and my experience developing protocols/guidelines, people get in touch to ask questions like this quite a lot. There are loads of questions that people ask - but there are lots of themes in common. We thought it was about time we produced a handy run down in the true spirit of #FOAMed.
Take a listen to Part 1 of our troponin podcast. While Simon and Iain have been prolifically churning out spectacular stuff for some time now, this is my debut on the St. Emlyn's podcast. I really enjoyed talking about troponin with Iain - and I hope we covered some useful stuff.
We'll cover more in part 2, when we'll move on to discussing high sensitivity troponins, what they are, how to use them and how to speak the troponin lingo. Please get in touch if there's anything we haven't covered that you'd like us to, or if there's anything you'd like us to elaborate on some more!
If you're starting out in EM then it can be a scary time. Iain and Simon talk through some of the initial anxieties and ask what you need to know to be safe, sensible and super.
It is a little known fact that to be successful as an emergency physician in the UK it is vital to take a three month rotation in Archery. Archery is a key skill for us all dating back to Medieval times when we introduced the longbow into warfare. This devastating tool could cause panic in opposing forces, scattering them into many wide and ineffective directions. In short they were an effective tool to cause and disruption inthe opposition ranks whilst the noble English armies of old strode forward with their visions of the future. Soldiers trained using targets to hone their skills and to focus on the aim - meeting the target.
Of course these days we do not have real bows and arrows in the emergency department, but archery remains alive and well. In the modern NHS we still train our troops in archery, or at least in the principle aim of archery - to meet the target.
With our long history of target setting and target hitting it is therefore no suprise that we are world leaders in standards/targets/indicators....., whichever term you prefer in fact and it has to be said that a target culture in the NHS has been criticised widely, even being blamed for the exodus of trainees to Southern climes, but there is arguably more to it than that.
In last weeks episode we touched on new targets around trauma care in the UK and that raised many questions and opened a debate on twitter. This week we want to take those thoughts further and ask what we, as the archiest of arch archers across the entire NHS can do with these externally set targets.
What we forgot to say in the podcast is the absolute need to work alongside a short stay admissions unit under the ED umbrella. Without that you would really struggle to deliver safe and efficient care. We both work in units with short stay admission units that allow us to deliver safe diagnostic and therapeutic interventions to our patients.
So, with some trepidation Iain and I ask whether all targets are a bad thing....
Iain and Simon discuss the challenges of getting our trauma patients to the CT scanner within 30 minutes of arrival.
The 30 minute target is a UK standard, and we did not set it! All UK trauma centres are judged against the target and (rightly or wrongly) it has become a real issue for many centres.
We would be really be interested in what our International colleagues think about the target and the resultant strategies outlined by the team. There's more on this at the St.Emlyn's website.
As always, we'd love to hear your comments.
Iain and Simon chat about how we can start to translate research findings in to natural frequency summaries that help clinicians and patients alike understand the value of therapeutic interventions.
The NNT site we mention is just fantastic. Visit them here http://www.thennt.com/
Great revision page here by the amazing LITFL crew http://lifeinthefastlane.com/education/ccc/risk-and-numbers-needed-to-treat/
The NNT for tranexamic acid is 67 not 50.
Hopefully you will have already seen and listened to my SMACC talk on 'What to believe and when to change'. If not then please whizz over to the site now and have a listen. I really enjoyed exploring the uncertainties that exist around when we decide to adopt or abandon therapies.
My belief is that it's really difficult to define the perfect moment and that it's only in retrospect that we can define it.
Since appearing on the ICN network and St.Emlyn's, Scott Weingart, one of the best and most innovative clinicians I know has come back and argued for early adoption. You can check out his rationale on his site and see what you think.
I actually agree with many of the things he tells us, although he has confined himself to one side of the argument. In terms of a defence of early adoption he makes a good case, but like all debates there needs to be another side to the story, so sit back and listen to why we must reflect hard on the decisions we make in deciding what we do, why we do it, and most importantly when.
Iain and Simon tackle the effect of prevalence on diagnostic performance. Mrs Trellis of North Wales makes a return appearance to discuss the delicate issues of sensitivity and Rick Body joins us by mail to raise concerns about the difficulties of missing patients with myocardial disease.
Listen and enjoy, visit the blog site and keep in touch.
The St.Emlyn's choirmaster has asked Iain and Simon to deliver a sermon on the importance of attending the SMACC Chicago conference in May 2015. After their pilgrimages to Australia in 2013 and 2014 they came back enthused and at times rather annoying about how jolly marvellous it all was.
A short podcast on the reasons why it's the little things that matter. Sure, we all love the latest shiny kit, but that's not what always matters and it's not how to move a system to excellence. In this short podcast we talk about why it's good to sweat the small stuff.
See the related blog post here.
A short version from the blog post on balanced sedation on the St.Emlyn's blog.
In summary, if you are going to be good at procedural sedation you need to evaluate the needs of the patient assess their needs and then select the appropriate drugs to tailor their effects to what the patient requires.
Here are my thoughts on the FCEM critical appraisal exam. They are based on a talk given at Gateshead in 2011 for the College conference. The ideas and recommendations are mine and mine alone. They do not represent the college view or any of the views of other examiners.
So, great if you find this helpful, but take it all at your own risk.
This podcast links to the blog post on the main St.Emlyn's website. It's a bit old now but hopefully will help you grasp the basics of sample size calculation. It should be very helpful to anyone considering the critical appraisal component of the FCEM exam.
Visit http://stemlynsblog.org/the-undertakers-ring-method/ for more information.
This is the undertakers trick. If you have arrived here then don't forget to visit the StEmlyns blog as well for more posts on EM topics.
2 caveats about this....I say that I've never cut a ring off. Sort of true as others have done it for me in two circumstances.
1. If there is a deep wound to the finger distal to the ring this is not a great method
2. If the ring did not come off before the injury due to bony (i.e. fixed) enlargement distally then clearly this won't work.
However, if they were able to get the ring off that morning, and now they cannot because of soft tissue swelling, and they can tolerate the discomfort of the procedure then this is a great technique.
Check out the better explanation here http://stemlynsblog.org/the-undertakers-ring-method/
And obviously, this is best done by someone who knows what they are doing, and you try it at your own risk.
More on basic interpretation of statistics for the critical appraiser. No maths, no formulas, no hard calculations. Just the tools to make the interpretation of results easier.
This week we look at relative risk (RR), absolute risk reduction (ARR) and number needed to treat (NNT). Are they different or the same?
You'll find that NNT is much more useful for the reader, things like relative risk have their place for statisticians and researchers who are seeking to understand their data. However, for clinicians and readers we would be better served by expressing data as NNT (or NNH).
This is not a stats lecture!
What I want to get across is that with very little knowledge you can have a really good go at interpreting the stats in the papers you read. No calculators, no maths, no hard sums, just an appreciation of whether it looks as though the authors did the right sort of thing.
In this podcast we look at different types of data, what p-values are and how do we define confidence intervals.
A short podcast on the basics of diagnostic test design. Hope you like it.
You may find these links useful.