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
Here’s our regular monthly round up of the best of the blog from March 2019
Our regular monthly round up of the best of the blog from Feb 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.
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.
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.
Karim Brohi joins the St.Emlyn's team at the London Trauma Conference to talk on vascular injury and arterial dissection. A whole range of diagnoses that you should not miss, but which is easy to miss.
Tricky!
Check out the blog post that accompanies this podcast here.
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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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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.
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.
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:
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
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?
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
Think! Do you really need an ABG? If the answer is yes, please use local anaesthetic! Your patients will thank you...
The Flipped EM Classroom - Shortness of Breath (with further links).
Natalie May
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:
Listen to Simon and Iain discuss how to approach these patients here
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
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!
Rick
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.
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Dear all,
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.
#FOAMed based academic emergency medicine from the St.Emlyn’s team. #Virchester #MedEd
