August 31, 2019
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
May 1, 2019
Here is the latest from the St Emlyn's team
April 24, 2019
Here’s our regular monthly round up of the best of the blog from March 2019
April 13, 2019
Our regular monthly round up of the best of the blog from Feb 2019.
April 10, 2019
Back in late 2018 we gathered in Manchester for the inaugural #stemlynsLIVE conference. Our friend Dr George Wills gave a great talk on Aortic Emergencies.
All emergency physicians know that it's all to easy to miss an aortic catastrophe. Listen to George's wisdom on common pitfalls and top tips to make you a better emergency clinician.
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Also check out these excellent #FOAMed resources.
- Subscribe to the blog (look top right for the link)
- Subscribe to our PODCAST on iTunes
- Follow us on twitter @stemlyns
- PLEASE Like us on Facebook
- Find out more about the St.Emlyn’s team
February 17, 2019
The latest blog posts, ideas and thoughts from the St Emlyn's podcast. This month with Simon Carley and Rick Body,
January 30, 2019
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.
May 22, 2015
Barbra Backus joins Rick Body to discuss the origin, development and future of risk scores for ED patients with possible acute coronary syndromes. Two researchers at the top of their game, and authors of the HEART and MACS scores.
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October 23, 2014
Rick and Iain explore how the latest guidance about the use of high sensitivity troponin was developed and how far we can be assured that it is evidence based.
The NICE guidance is available here. http://www.nice.org.uk/guidance/dg15
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August 7, 2014
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:
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.
Rick
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.
August 3, 2014
Breathless patients are a challenge in the ED. Shortness of
breath can be a frightening presenting complaint for both patients and
doctors. As always, think about the possible life threatening causes and
actively rule them out. For breathless patients think especially about:
- Pneumonia
- Asthma/COPD
- Pulmonary Embolism
- Acute left ventricular failure
- Pneumothorax
Breathless Patients Podcast
In
this podcast Iain and Simon discuss their approach to
breathless patients in the ED which we hope will provide you with a good
starting point.
For
those of you who are more visual learners here is the video recorded a
few years ago for SEMEP featuring our very own Iain Beardsell.
http://vimeo.com/35310564
Take Home Points
- Oxygen should be used in the patient with shortness of breath and the patient monitored closely. Hypoxia kills
- Always rule out life threatening causes first
- These patients are sick - do not be afraid to ask advice from a senior colleague early
- Look for clues - you don't have to wait until the penultimate page of the story to solve the mystery.
What have you learned about breathless patients?
Oxygen - or no oxygen??
Oxygen administration is rarely a problem in the immediate and acute
setting - and can save lives. So yes, when you first approach a patient
who is short of breath, get that oxygen on while you make your
assessment then think about the finer points of respiratory failure
afterwards.
Where do I begin?
A focused history, including asking the patient about previous conditions and whether they know what's going on!
And then - initial assessment and examination including vital signs
(especially respiratory rate), looking for clues as to the underlying
cause of their breathlessness, remembering the five common causes.
What treatments might be useful?
A small fluid bolus might help and carries relatively little risk;
think about the need for nebulised bronchodilators for patients with
asthma or COPD, and remember that antibiotics given early to patients
with sepsis save lives.
If the patient has pain we should definitely treat that too.
Which investigations might help me find out more?
- A
chest x-ray is often useful in patients who are short of breath; your
ED seniors might be able to use bedside ultrasound to further ascertain
the underlying pathology, so get help early!
- ECGs are often useful in these patients
- Blood
gases can also provide lots of useful information - think carefully
about whether you need arterial gases and if so, please use local
anaesthetic.
- If nothing makes sense - get a blood sugar,
remembering that metabolic disease may cause an acidosis, presenting
with an increased respiratory rate (although not often true dyspnoea).
- And
GET SENIOR HELP (including getting your seniors to assess you for those
all-important workplace-based assessments; definitely start those
early)
Other resources
Chest Radiographs
One
of the key investigations in patients with shortness of breath is the
humble chest radiograph. There are some phenomenal FOAM resources for
interpretation of CXRs (along with other XRs) at Radiology Masterclass. Well worth bookmarking for your ED shifts (but do ask a senior if you're unsure).
Chest X-Ray Anatomy - Chest X-Ray Abnormalities - Chest X-Ray Systematic Approach
Blood Gases
Think! Do you really need an ABG? If the answer is yes, please use local anaesthetic! Your patients will thank you...
Further Reading on Shortness of Breath
The Flipped EM Classroom - Shortness of Breath (with further links).
Natalie May
August 1, 2014
We've all had headaches, but not often severe enough to prompt us to seek help in an Emergency Department.
In
our practice 10% of patients who do present to the ED with a primary
presentation of headache will have serious pathology and our job as
Emergency Physicians is to work out who these are. Key to this is
actively ruling out the life-threatening and life-changing diagnoses:
- Subarachnoid Haemorrhage
- Meningitis
- Tumours and Space Occupying Lesions
- Temporal Arteritis
Listen to Simon and Iain discuss how to approach these patients here
Further Resources
Headaches at Life in the Fast Lane - a great summary from the LiTFL crew
NICE Guidelines (NCG150) - diagnosis and management of headaches; there's a flowchart and some red flags although you could read the St Emlyn's summary here!
Headache from the Flipped EM Classroom
July 27, 2014
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:
- What is cardiac troponin?
- Why is it a marker of AMI?
- What else causes a raised troponin and how?
- Should we be doing troponins at 3 hours, 6 hours, 12 hours? What's the difference and what's the evidence?
- What is a 'delta troponin'?
- What do you need to 'rule in' AMI?
- How do you use cardiac troponin in patients with renal failure?
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!
Rick
June 22, 2014
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.
Don't forget to subscribe to the podcast via iTunes, to subscribe to the blog site and to like us on facebook.
vb
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June 15, 2014
Dear all,
It would appear that the organ member was correct and we cannot be certain about the organ pipes. Apparently there are doubts about whether they are safe or need replacing.
We will once again turn to Dr Beardsell and Prof. Carley to see if there is anything more that we can do. As I am due to allocate funds for repairs to musical instruments this year then we must ensure that these are spent wisely.
If there is a less than 2% chance of failure we will wait. If there is a greater than 50% chance of failure then we should spend the money.
The situation is uncertain and we need help.
I have the honour to be et. etc. etc.
The Choirmaster at St.Emlyn's
June 10, 2014
A podcast discussing sensitivity and specificity of diagnostic tests and how we can use this in our everyday medical care of patients.
This article from the Centre for Evidence Based Medicine is also useful.
