The St.Emlyn’s Podcast

In this episode of the St Emlyn’s Podcast, Iain Beardsell and Simon Carley talk with Caroline Leech at the BASICs Conference about resuscitative hysterotomy following maternal cardiac arrest.

This is a calm, evidence-led discussion of a rare, high-stakes intervention that most clinicians will encounter once, if at all — and still need to get right.

What we cover

• Why the term resuscitative hysterotomy has replaced perimortem caesarean section

• The physiological rationale: relieving aortocaval compression to improve maternal resuscitation

• What the evidence actually shows about timing, maternal survival, and neonatal outcomes

• Findings from Caroline’s systematic review of out-of-hospital cardiac arrest in pregnancy

• Why the “4–5 minute rule” does not reflect real-world pre-hospital care

• Neonatal survival at far longer timelines than traditionally taught

• Practical decision-making in pre-hospital and emergency department settings

• Who should perform the procedure, and why speed matters more than seniority

• Aftercare challenges: open abdomen, placenta management, bleeding (or lack of it)

• Team cognitive load, role allocation, and when termination at scene is appropriate

• The emotional and professional impact on clinicians and families

Key takeaways

• Maternal survival after out-of-hospital arrest is rare, but not zero

• Neonatal survival is higher than often appreciated, even with prolonged timelines

• Delaying purely to reach hospital or a specialist may reduce benefit

• The hardest part is not the incision — it is the decision, coordination, and aftermath

• Training should focus as much on judgement and communication as on technical skill

This episode is not about heroics.
It is about realism, evidence, and being prepared for one of the most confronting moments in emergency care.

About MedPod Learn

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with tools to support reflection, CPD, and appraisal.

Available on the App Store and Google Play.

IncrEMentum 2026 - April 22 - 24

IncrEMentuM was born to revolutionise how we approach emergency medicine. It’s not a traditional conference — it’s an immersive experience that pushes professionals to act, think, and make decisions in real time.

Our mission is to bring together healthcare providers, experts, and emergency personnel from around the world to share experiences, train in realistic scenarios, and test their skills under extreme pressure.

In 2026, we return with an even more intense and lifelike edition — all with one clear goal: to prepare you for what cannot be predicted.

Tactical Trauma - April 22 - 24

This is an international conference covering various aspects of working in high-stakes environments, primarily related to pre-hospital trauma and critical care, with a tactical twist.

Our program is rich and diverse, featuring state-of-the-art lectures from world-class speakers. We aim to bring together all organisations working with pre-hospital trauma in tactical/hostile environments, including physicians, HEMS, EMS, police anti-terror units, military, fire and rescue services and more.

 

In this (rather delayed!) October round-up, Iain Beardsell and Simon Carley catch up on recent St Emlyn’s blog posts and papers that continue to shape emergency and resuscitation practice.

The discussion moves across trauma, analgesia, cardiac arrest physiology, emergency department systems, and antimicrobial stewardship—less about novelty, more about what actually holds up on shift.

Trauma and haemorrhage

The episode opens with a discussion of the FIRST-2 trial, examining fibrinogen concentrate and prothrombin complex concentrate versus fresh frozen plasma in severe traumatic haemorrhage.
Despite promising physiological theory, the trial shows no meaningful reduction in blood product use compared with standard care, reinforcing the ongoing role of FFP in early trauma resuscitation.

Upper limb injuries and regional anaesthesia

The team explore the SUPERB trial comparing supraclavicular brachial plexus blocks with Bier’s blocks for upper limb reductions.
Both techniques provide excellent analgesia. The conversation reflects on changing practice, procedural sedation pressures, ultrasound access, and how physical space—not evidence—often dictates what we do.

Cardiac arrest: signals worth paying attention to

Three recent cardiac arrest papers are reviewed, focusing on physiological markers rather than new devices:

• End-tidal CO₂ as a CPR quality target

• Ventilation strategies during arrest, including chest-compression-synchronised ventilation

• Cerebral oximetry as a potential prognostic signal

These are not definitive answers, but they point towards cardiac arrest management that is more physiological and less ritualistic.

Emergency department systems: repair, not reinvention

A reflective discussion on “designer repair” challenges the idea that emergency departments need constant transformation.
Instead, the focus shifts to recognising and supporting the clinicians quietly holding fragile systems together every day—and why fixing small, broken things often matters more than grand redesigns.

Sepsis and antibiotics

The episode closes with a critical look at broad-spectrum antibiotic use in suspected sepsis.
Observational data suggest significant overtreatment and real harm, reinforcing the need to pause, think, and choose the right antibiotic—not just the fastest one.

This episode is a reminder that good emergency medicine is rarely about silver bullets.
It’s about judgement, physiology, and paying attention to what actually works in the real world.

About MedPod Learn

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with tools to support reflection, CPD, and appraisal.
Available on the App Store and Google Play.

Emergency medicine strips decision-making back to its essentials when departments are full and time is short.

This first episode in the Best Bits of 2025 series brings together some of the most practically useful moments from the St Emlyn’s podcast this year — focusing on how clinicians make good decisions under pressure, when conditions are far from ideal.

Each clip comes from a full episode released in 2025.

In this episode, we explore:

• How ten-second triage is designed to work on “worst-day” scenarios, not in textbooks

• The uncomfortable truth about why procedures sometimes get done — and why that matters

• Why time, not technique, is often the limiting factor in resuscitative thoracotomy

• The case for earlier invasive monitoring in the sickest patients

• Where thinking around double sequential defibrillation may be heading

This episode is designed to be useful on shift, in the car, or during a quiet moment before the next job.

Featured episodes

Clips in this episode are taken from the following full St Emlyn’s episodes:

• Episode 257 — Ten Second Triage with Sean Brayford-Harris (Tactical Trauma 24)

• Episode 269 — Monthly Round Up (January 2025): Decision-making and prehospital RSI

• Episode 270 — Insights on Cannabis Edibles, Pre-Hospital Thoracotomy and more

• Episode 266 — Monthly Round Up (February 2025): Targeted resuscitation and arterial lines

• Episode 268 — Top Papers of 2024 from The Big Sick Conference

All full episodes are available in the podcast feed.

About MedPod Learn

MedPod Learn is a clinician-built medical podcast player designed to turn listening into structured learning, with optional MCQs, reflection prompts, and saved activity for appraisal and CPD.
You can find it on the App Store and Google Play.

In this special edition of the St Emlyn’s podcast, Iain Beardsell and Simon Carley review the top medical papers of 2024, originating from Simon’s talk at The Big Sick conference in Zermatt. The discussion includes a comparison of non-invasive versus arterial pressure monitoring, the association of intra-arrest arterial blood pressure with ROSC, the efficacy of serratus anterior plane blocks for rib fracture management, and the evaluation of a micro axial flow pump in cardiogenic shock.

They also delve into double sequential external defibrillation in refractory out-of-hospital cardiac arrest and provide a rapid-fire review of additional critical papers discussed at the conference. Notable mentions include the HEMOTION trial, PRE OXI trial, BLING III, and PARAMEDIC-3, among others.

A must-listen for those passionate about evidence-based medicine in emergency and pre-hospital care.

You can read more about all the trials, including links to all the papers here (part 1) and here (part 2)

00:00 Introduction and Conference Highlights

01:51 Non-Invasive vs. Arterial Pressure Monitoring

03:28 Intra-Arrest Blood Pressure and ROSC

05:34 Serratus Anterior Plane Blocks for Rib Fractures

08:38 Micro Axial Flow Pump in Cardiogenic Shock 10:49 Double Sequential Defibrillation in Cardiac Arrest

13:17 HEMOTION Trial

15:01 PRE OXI and BLING III Trials

17:08 Fluid Management in Septic Shock

18:37 Expedited Transfer vs. On-Scene Resuscitation

20:39 Intraosseous vs. Intravenous Access

21:48 Conclusion and Final Thoughts

In this episode, hosts Iain Beardsell and Simon Carley provide the St Emlyn's podcast blog update for July 2024. They discuss their recent experiences, including Simon's trip to Malaysia for the MRCEM exams and Iain's upcoming attendance at the Tactical Trauma conference in Sweden.

The main topics include a systematic review on the Manchester Acute Coronary Score (MACS) and its application in emergency departments, the potential influence of AI in diagnosing occlusive myocardial infarctions through ECGs, and guidelines for managing non-fatal strangulation cases. Additionally, they touch on the feasibility of using lidocaine patches for elderly patients with rib fractures and the role of partial REBOA in pre-hospital care for exsanguinating subdiaphragmatic haemorrhage.

They also highlight informative segments from the premier conference on pediatric emergency medicine, covering topics such as eating disorders, hybrid closed-loop insulin pumps, and button battery ingestion. Finally, they emphasize the importance of understanding medical statistics and using diagnostic tests effectively in emergency medicine practice.

00:00 Introduction and Summer Updates

00:55 Upcoming Conferences and Events

01:44 Manchester Acute Coronary Score (MACS) Review

05:30 AI in ECG Analysis with Steve Smith

08:18 Non-Fatal Strangulation Awareness

10:45 Reboa: Pre-Hospital Use and Insights

14:11 Pediatric Emergency Medicine Highlights

14:36 Eating Disorders and Diabetes Management

19:00 Lidocaine Patches for Rib Fractures

21:46 Critical Appraisal and Medical Statistics

24:28 Button Battery Ingestion Dangers

26:12 Conclusion and Farewell

As the UK enjoys its unpredictable summer, with everything from sunshine to hailstorms, we bring you a mix of updates and discussions on emergency medicine, blog content, upcoming conferences, and insightful research reviews. So, whether you're basking in the sun or sheltering from the rain, sit back and enjoy our latest insights into the world of emergency medicine.

In this round-up of Month Year, we talk about a wide range of issues relating to emergency medicine, including nebulised ketamine for analgesia in the ED, risky intubations, presentation skills, more about the DOSE VF trial and analysis of the much-hyped PREOXI trial about preoxygenation before tracheal intubation.

We're excited to announce our participation in two upcoming conferences. The Tactical Trauma Conference in Sweden this October promises to delve into pre-hospital emergency medicine, offering sessions from renowned speakers. It's a fantastic opportunity to learn and network, with flights to Sweden being relatively affordable. The event takes place just north of Stockholm, providing a chance to explore the beautiful city.

In March next year, we look forward to the Incrementum Conference in Murcia, Spain. This is a significant event as emergency medicine has recently been recognized as a specialty in Spain. The conference will feature an impressive lineup of speakers from the FOMED world, including Scott Weingart, Ken Milne, Hany Malamatt, and Slim Resie , among others. Our very own Simon Carly will also be presenting. We'll be there to conduct interviews and gather exclusive content for our listeners.

Thank you for joining us, please do like and subscribe wherever you get our podcasts.

 

Welcome to the St Emlyn's Monthly Podcast, your go-to source for the latest insights, developments, and discussions in emergency medicine and critical care. Each month, Simon and Iain will bring you in-depth analysis, evidence-based practices, and practical advice to enhance your clinical practice and professional development. 

In this round-up of May 2024, we talk about a wide range of issues relating to emergency medicine, including highlights from the RCEM conference, including the future management of head injury, crowding, RATing and what it takes to be an awesome ED for training. There's also advice on how to be a epic Emergency Physician In Charge, as well as discussion about the use of ChatGPT for medical exams, serratus anterior blocks for rib fractures, whether first pass success matters and the return of measles.

Thank you for joining us, please do like and subscribe wherever you get our podcasts.

An EBM-packed episode where Iain and Simon go over ten of the top papers from the last year discussing all manners of things Emergency Medicine, including TXA in trauma, use of video laryngoscopy, defibrillation strategies in refractory VF, and ten-second triage in major incidents. There's also a very pertinent discussion about whether the age of your Emergency Physician might affect your outcome...

Thank you again for listening to the St Emlyn's podcast. Please do like and subscribe and get in touch if there is anything you'd like us to discuss or if you'd like to get involved. 

After a long, hot and relaxing summer (!) Simon and Iain return with all the content from the St Emlyn's blog in July and August. They discuss four papers in detail, including the ARREST trial about cardiac arrest centres, whether clinical examination can identify life threatening injuries in trauma, the TOP-ART study looking at a novel agent in trauma management and the use of REBOA. 

Please do like and subscribe and get in touch if you would like to contribute to the blog site. 

This is the first in a series of podcasts, recorded live at the Premier Conference in Winchester.

In this episode, David James challenges our current practice when we give a 'weaning plan' for children discharged with wheeze. 

There is a plan here that you can review and give to patients and their carers.

More information at these excellent websites

• PIER Network
• Southampton Oxford Retrieval Team
• Healthier Together

David James has been a PEM Consultant at University Hospital Southampton since 2018. His main interests are in training and education, adolescent emergency medicine and Quality Improvement. He is the Divisional Director of Medical Education and a Training advisor on the PEMISAC. He is the acute care lead for Wessex Healthier Together and has led several projects including those around acute wheeze at UHS and regionally. Outside of work he enjoys swimming, cycling and running and is extremely average at triathlons.

 

The latest CAN is one of our brand-new 'revision editions' -- brief podcasts aimed at covering the essentials of critical appraisal for medical students and junior doctors preparing for exams.

With the help of Gregory Yates, an academic doctor based in Manchester, this episode introduces two core concepts: sensitivity and specificity. These are two ways of thinking about the accuracy of a diagnostic test. Knowing the sensitivity and specificity of an investigation will give you a decent idea of how it should be used in the emergency department.

Sensitivity (Sn) describes the chance that a test will be positive if your patient has the condition you're testing for. Some people call it the 'true positive rate' or alternatively the positivity in disease (PID) rate. If you need a hand remembering it, you can always remember that PID is a sensitive issue.

 

Meanwhile, specificity (Sp) considers the chance of a test being negative if the patient doesn't have the condition you're testing for. It's the 'true negative rate' or alternatively the negativity in health (NIH) rate. There are times when we particularly need a test to have a high sensitivity. This is generally when we want to be particularly confident that a test accurately identifies everyone with the relevant condition because we really don't want to miss it. We need a high sensitivity to rule out disease. (Sn-uff it out). At other times, we need to be confident that a patient with a positive test actually has the disease - for example, if the treatment is unpleasant or involves exposing patients to risk. In that case, we want a high specificity to rule in disease. (Sp-in it in).

 

In this CAN, we use D-Dimer as an example of a very sensitive investigation: it’s positive in nearly 100% of cases of venous thromboembolism. Specificity describes the likelihood that the test will be negative if your patient does not have the disease. We use HbA1c as an example of a highly specific investigation: it’s rarely used in the emergency department, but if it’s elevated, we can be almost certain that the patient is diabetic. HbA1c is almost never (<1%) raised in non-diabetics.

The trouble is, many patients with a positive D-Dimer do not have a venous clot, and the majority of diabetics will have a normal HbA1c! No test is perfect, and we discuss how emergency physicians weigh up sensitivity and specificity when choosing which investigations are the best "fit" for clinical decision-making. By the end of this CAN, you will be ready to do the same -- in your exams, and on the shop floor.

 

Our regular monthly round up and chat from the St Emlyn's blog. We talk about the use of artificial intelligence in research and the use of remifentanil instead of neuromuscular blockade in rapid sequence intubation. Plus more about the StEmlynsWILD conference and Simon's new role as Dean of RCEM and how you can get involved. 

Long term listeners to the St Emlyn’s podcast may remember our series entitled ‘Critical Appraisal Nuggets’ (CANs). We are absolutely delighted to reinvigorate this project under the leadership of Professor Rick Body, with the episode on semi structured interviews.

In this easily digestible and succinct podcast Rick and Laura Howard go through the pros and cons of setting up semi structured interviews and how these can be used effectively in qualitative research.

In the latest episode, we cover a qualitative research technique: semi-structured interviews. Qualitative research might be out of your comfort zone: we’re generally more comfortable with quantitative measures – numbers and statistics. It’s something they have experience with, having previously published a paper exploring the impact of events that happen at work on the wellbeing of emergency physicians. This was a labour of love for Laura. Laura wrote a powerful blog about it here.

Semi-structured interviews are a great way to get the really rich data we need to understand something in greater depth. They allow us to ask ‘why?’ as well as just ‘what?’, ‘who?’ and ‘when?’. But reading qualitative research papers can be difficult when it takes us out of our comfort zone. In this CAN podcast, Laura and Rick take us through what semi-structured interviews are, why we might use them, how you design and conduct them, and they also have some pearls of wisdom about how to make transcribing them a lot less painful. By the end, we hope that you’ll feel confident with the basics of the technique. And if you want to practice your critical appraisal, why not put their study under the microscope?

This is our round up of all that happened on the St Emlyn's blog in August 2022 (yes - we know it's a bit late, but there's been a lot going on!).

Listen to Simon and Iain discuss the latest therapies in COVID, particularly Baricitinib, calcium in trauma and how we find balance in our work-life blend.

Please do like and subscribe to the podcast and tell your friends and colleagues. We've lots of exciting stuff coming your way over the next few months.

Simon and Iain run through the latest highlights from the St Emlyn's blog and podcast, including the FORCE study, the EXIT study and more about Vitamin C in sepsis...

 

We hope you enjoy the podcast. Please do like and subscribe on your preferred podcast app and tell your friends and colleagues about us. 

Our monthly round up of all from the St Emlyn's blog. We discuss pathways into emergency care research, pad positioning in cardioversion of AF and possible gender differences in the presciption of TXA in trauma.

We also chat about travel in Lithuania, memories of defibrillating with hand held paddles and Simon's recent forst infection with COVID.

We mention a post on Lyme disease which you can read here (especially if you live near the New Forest...)

 

A podcast with Iain and Simon summarising all the latest content from the St Emlyn's blog in April 2021. Topics discussed include Vaccine Induced Thrombocytopenic Thrombosis, how our own biases can effect our critical appraisal and whether we need to worry about grading the quality of FOAMed resources.

Thanks for listening. Please check out the blogs themselevs at www.stemlynsblog.org and consider subscribing and rating us on iTunes. 

If you'd like to see some more from Peter Brindley you can watch one of his SMACC talks here. 

Our own version of Buy One Get One Free* this month, where you get a round up of two months of blog content.

 

Coronavirus continues to dominate the medical (and non-medical) headlines, and we discuss the two major results from the RECOVERY trial published recently, one positive and one not so (depending on who you talk to....). Simon also catches up with Roberto Cosentini, who you'll remember from the very powerful podcast at the beginning of the pandemic.

 

COVID isn't the only EBM circus in town though: we've reviewed HALT-IT and Simon has given a talk about the "Ten Top Trauma Papers" of the last year and Laura reviewed a paper looking at haloperidol for headaches.

 

We're having to think even harder about how we communicate in the ED, both for clinical care and to deliver education. Two ideas to help learning have been featured this month: The St Emlyn's Lesson Plans and "Background Learning". 

 

Good luck to all those starting in Emergency Medicine, and a huge thank you to all those who are moving to other areas of medicine or other departments. It's been a curious few months...

 

Take care,

 

Iain

*It's actually Get One Free Get Another Free, but whose ever heard of that?

 

 

Welcome to our fifth webinar and journal club reviewing recent research and featuring COVID-19 updates, hosted by the University of Manchester, Manchester Royal Infirmary and Royal College of Emergency Medicine in collaboration with St Emlyn’s.

The live event took place on Tuesday 12th May at 11.00am BST (10.00am GMT). 

The COVID-19 Journal Club Panel

Today’s panel was hosted by Rick Body The panel includes Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Prof Dan Horner, Dr Anisa Jafar, Prof Pam Vallely (Professor of Medical Virology), Prof Simon Carley and special guest Lauren Westafer (Attending in Emergency Medicine and Co-Creator of the Foamcast blog and podcast) and Ellie Hothershall (head of undergraduate medicine at the University of Dundee and an expert in Public Health) to discuss six papers about COVID-19 infection.

1. Lai S, Ruktanonchai NW, Zhou L, et al. Effect of non-pharmaceutical interventions to contain COVID-19 in China. Nature. May 2020. doi:10.1038/s41586-020-2293-x

2. Paranjpe I, Fuster V, Lala A, et al. Association of Treatment Dose Anticoagulation with In-Hospital Survival Among Hospitalized Patients with COVID-19. Journal of the American College of Cardiology. May 2020. doi:10.1016/j.jacc.2020.05.001

3. Thanh L, Andreadakis Z, Kumar A, et al. The COVID-19 vaccine development landscape. Nat Rev Drug Discov. 2020;19(5):305-306. doi:10.1038/d41573-020-00073-5

4. Bryan A, Pepper G, Wener MH, et al. Performance Characteristics of the Abbott Architect SARS-CoV-2 IgG Assay and Seroprevalence in Boise, Idaho. J Clin Microbiol. May 2020. doi:10.1128/jcm.00941-20

5. Treibel TA, Manisty C, Burton M, et al. COVID-19: PCR screening of asymptomatic health-care workers at London hospital. The Lancet. May 2020. doi:10.1016/s0140-6736(20)31100-4

6. Altmann S, Milsom L, Zillessen H, et al. Acceptability of app-based contact tracing for COVID-19: Cross-country survey evidence. May 2020. doi:10.1101/2020.05.05.20091587

 

Podcast edited from a live webinar by Izzy Carley

Welcome to our fourth webinar and journal club reviewing recent research and featuring COVID-19 updates, hosted by the University of Manchester, Manchester Royal Infirmary and Royal College of Emergency Medicine in collaboration with St Emlyn's.

 

The live event tool place on Tuesday 5th May at 11.30am BST (10.30am GMT). 

 

The panel was again be hosted by Rick Body The panel includes Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Dr Anisa Jafar (Academic Clinical Lecturer), Prof Pam Vallely (Professor of Medical Virology), Prof Simon Carley and special guest Justin Morgenstern to discuss six papers about COVID-19 infection.

 

There will be another COVID 19 Journal Club next week (Tuesday 12th May at 11am).

 

References

1. He X, Lau EHY, Wu P, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med. Published online April 15, 2020. doi:10.1038/s41591-020-0869-5

 

2. Bahl P, Doolan C, de Silva C, Chughtai AA, Bourouiba L, MacIntyre CR. Airborne or Droplet Precautions for Health Workers Treating Coronavirus Disease 2019? The Journal of Infectious Diseases. Published online April 16, 2020. doi:10.1093/infdis/jiaa189.

 

3. Wang Y, Zhang D, Du G, et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. The Lancet. Published online April 2020. doi:10.1016/s0140-6736(20)31022-9

 

4. Rajendran K, Narayanasamy K, Rangarajan J, Rathinam J, Natarajan M, Ramachandran A. Convalescent plasma transfusion for the treatment of COVID‐19: Systematic review. J Med Virol. Published online May 2020. doi:10.1002/jmv.25961

 

5. Tedeschi S, Giannella M, Bartoletti M, et al. Clinical impact of renin-angiotensin system inhibitors on in-hospital mortality of patients with hypertension hospitalized for COVID-19. Clinical Infectious Diseases. Published online April 27, 2020. doi:10.1093/cid/ciaa492

 

6. Docherty AB, Harrison EM, Green CA, et al. Features of 16,749 hospitalised UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol. Published online April 28, 2020. doi:10.1101/2020.04.23.20076042

 

Podcast edited from a live webinar by Izzy Carley 

 

It's been another busy month at St Emlyn's, with the publication of 15 blog posts and five podcasts, but there does seem to be an awful lot to talk about!

 

Of course there have been multiple posts and podcasts about COVID-19, and you can fiind all of these on our special St Emlyn's page. Highlights have included the three RCEM/St Emlyn's Webinars which we are delighted to host in podcast form.

 

It's not just been coronavirus though, we have also dipped out toes into exercise and nutrition, graphic design and horticulture!

 

Parts of the site have also undergone a bit of a redesign with the curriculum pages now easier to navigate to find that post to fioll an e-portfolio hole.

 

 

We hope you're finding all of our output useful. Please do subscribe to the website (in the top right hand corner) and rate our podcast on iTunes.

 

They'll be much more to come in May I am sure.

 

Take care

 

Iain

Podcast edited by Izzy Carley

 

Welcome to our second webinar on recent research about COVID-19, hosted by the University of Manchester, Manchester Royal Infirmary and Royal College of Emergency Medicine in collaboration with St Emlyn’s.

The panel was hosted by Rick Body. The panel includes Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Prof Pam Vallely (Professor of Medical Virology), Dr Anisa Jafar (Academic Clinical Lecturer), Dr Casey Parker and Prof Simon Carley (you know him…) to discuss six papers about COVID-19 infection.

The live event took place on Tuesday 21st April 2020

References: 

Paper 1 (00:00) Tang W, Cao Z, Han M, et al. Hydroxychloroquine in patients with COVID-19: an open-label, randomized, controlled trial. April 2020. doi:10.1101/2020.04.10.20060558

Paper 2 (12:09) Bendavid E, Mulaney B, Sood N, et al. COVID-19 Antibody Seroprevalence in Santa Clara County, California. April 2020. doi:10.1101/2020.04.14.20062463

 

Paper 3 (16:40) Wölfel R, Corman VM, Guggemos W, et al. Virological assessment of hospitalized patients with COVID-2019. Nature. April 2020. doi:10.1038/s41586-020-2196-x

 

Paper 4 (23:33) Favas C. Guidance for the Prevention of COVID-19 Infections among High-Risk Individuals in Camps and Camp-like Settings. London School of Hygiene and Tropical Medicine; 2020:1-15. https://www.lshtm.ac.uk/sites/default/files/2020-04/Guidance%20for%20the%20prevention%20of%20COVID-19%20infections%20among%20high-risk%20individuals%20in%20camps%20and%20camp-like%20settings.pdf. Accessed April 21, 2020.

 

Paper 5 (30:30) Zeng J-H, Liu Y-X, Yuan J, et al. First case of COVID-19 complicated with fulminant myocarditis: a case report and insights. Infection. April 2020. doi:10.1007/s15010-020-01424-5

 

Paper 6 (35:02) Caruso D, Zerunian M, Polici M, et al. Chest CT Features of COVID-19 in Rome, Italy. Radiology. April 2020:201237. doi:10.1148/radiol.2020201237

 

Podcast edited by Izzy Carley and Iain Beardsell

In this podcast, Dan and Iain talk about the clinical journey of a COVID-19 patient, beyond the ED, with insights from the critical care unit. There are some concepts here that we don’t have time to do full justice to in the podcast, so there is a comprehensive set of "show notes" and all the references at www.stemlynsblog.org/covid-19-and-critical-care

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

Simon interviews Dr John Rogers and Dr Nathan Lewis on respiratory infection prevention.

John a Sports and Exercise Medicine Consultant in Manchester. He is also Chief Medical Officer for British Triathlon and Visiting Professor in Sport & Exercise Medicine at Manchester Metropolitan University.

Nathan is lead performance nutrition scientist at the English Institute of Sport and at ORRECO.

These two academics take us through how sports science might be able to support our wellbeing during the Covid19 pandemic.

 

References

1. Recommendations to maintain immune health in athletes https://www.tandfonline.com/loi/tejs20
2. Probiotics https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006895.pub3/epdf/full 
3. Vitamin D and Respiratory Tract Infections: A Systematic Review and Meta-Analysis of Randomized Controlled Trials https://pubmed.ncbi.nlm.nih.gov/23840373/
4. Vitamin C for prevention and treatment of pneumonia https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013134/full
5. Vitamin C and common cold https://www.cochrane.org/CD000980/ARI_vitamin-c-for-preventing-and-treating-the-common-cold 
6. Effect of Flavonoids on Upper Respiratory Tract Infections and Immune Function: A Systematic Review and Meta-Analysis https://pubmed.ncbi.nlm.nih.gov/27184276/
7. Vitamin C and Infections https://pubmed.ncbi.nlm.nih.gov/28353648/
8. Zinc lozenges and the common cold: a meta-analysis comparing zinc acetate and zinc gluconate, and the role of zinc dosage https://pubmed.ncbi.nlm.nih.gov/28515951/

 

 

 

Iain is back on the podcast with Simon to talk through the best of the blog from January 2020.

A Comprehensive Review of St Emlyn’s Blog: August 2019 Highlights

Welcome to St Emlyn’s blog and podcast, where we reflect on the key topics and research from August 2019. In this review, we’ll explore the most impactful discussions and studies, providing valuable insights for emergency medicine professionals. From managing lower GI bleeding and addressing climate change in anaesthesia to examining PTSD in emergency services and the future of diagnostics, this post summarizes essential takeaways that are shaping our field.

Managing Lower GI Bleeding in the Emergency Department

One of the significant topics covered was the management of acute lower gastrointestinal (GI) bleeding, a common but challenging condition in the emergency department (ED). The complexity of managing these cases often lies in determining the correct priority of care, appropriate management strategies, and even the correct speciality for handling these patients.

We reviewed a consensus guideline from the British Society of Gastroenterology and Hepatology, published in Gut, which offers practical recommendations for the diagnosis and management of acute lower GI bleeds. The guideline emphasizes the importance of using stratification tools to distinguish between stable and unstable patients, which can help streamline management in the ED.

For stable patients, the Oakland score is recommended. This scoring system helps identify which patients can be safely managed on an outpatient basis, reducing unnecessary hospital admissions. Conversely, patients with a major bleed should be admitted and scheduled for a colonoscopy at the earliest opportunity. The guideline also highlights the value of CT angiography for hemodynamically unstable patients, a practice increasingly integrated into emergency care.

Transfusion thresholds, set at 70 grams per litre, align with standard practices in other clinical settings, with adjustments for patients with cardiovascular disease. The guideline also recommends having dedicated GI bleed leads within trusts to ensure seamless coordination with emergency services.

Sustainability and Climate Change in Anesthesia

Another crucial discussion from August focused on the environmental impact of healthcare, particularly in anaesthesia. In the UK, healthcare is a significant contributor to climate change, driven by factors like travel, disposable materials, and the use of anaesthetic gases such as nitrous oxide and desflurane.

A key paper by Cliff Shelton and colleagues underscores the need to adopt more sustainable practices in anaesthesia. For example, desflurane is approximately 3,000 times more potent as a greenhouse gas than carbon dioxide. The paper advocates for reducing the use of high-polluting gases and considering greener alternatives where possible.

This shift towards sustainability in healthcare is essential, although challenging, given the nature of medical practice. However, small changes, such as reducing nitrous oxide use in departments where alternatives exist, can collectively make a significant difference. The paper serves as a call to action for healthcare professionals to be more mindful of their environmental impact and to seek sustainable solutions in their practices.

Pre-Hospital Care: Comparing Macintosh and McGrath Laryngoscopes

The debate over the best laryngoscope for pre-hospital rapid sequence intubation (RSI) is ongoing, and in August, we reviewed a study that contributed valuable data to this discussion. Published in Critical Care Medicine, the study compared the Macintosh and McGrath laryngoscopes in pre-hospital settings, involving 514 adult emergency patients.

The study found that both devices were equally effective for pre-hospital RSI. Notably, it also revealed that switching to a different device after a failed intubation attempt was more successful than repeating the attempt with the same device. This finding aligns with the 30-second RSI drills many practitioners use, which advocate for changing the approach after a failed attempt.

These findings have practical implications for both pre-hospital and in-hospital care. In the ED, switching to a video laryngoscope, such as the McGrath, after a failed intubation attempt could improve patient outcomes. As video laryngoscopes become more accessible in emergency departments, integrating them into RSI protocols could be a beneficial strategy.

PTSD in Emergency Services: Rusty Carroll’s Series

Rusty Carroll’s ongoing series on PTSD within the ambulance service continues to be one of the most impactful contributions to the St Emlyn’s blog. The August instalment focused on the aftermath of PTSD, exploring the journey towards understanding what “normal” looks like after such an experience.

Rusty’s candid reflections resonate with many in the emergency services community, highlighting the mental health challenges prevalent in our field. The series has received positive feedback, with many readers finding comfort and validation in Rusty’s experiences.

However, the widespread relatability of this series also underscores a concerning reality: many emergency service professionals are struggling with similar issues. As a community, we need to support one another, promote mental health awareness, and advocate for resources to address the psychological toll of our work. Revisiting Rusty’s previous installments in this series is highly recommended for a deeper understanding of the complex emotions associated with PTSD in emergency services.

The Realities of Packed Red Cell Transfusions

Another fascinating topic from August was the metabolic and biochemical characteristics of packed red cell transfusions, which have significant implications for trauma care in the ED. This discussion was sparked by a conversation on Twitter, leading to critical reflections on the assumptions we hold about blood transfusions.

In trauma care, blood is often regarded as a superior alternative to crystalloids. However, the reality of what we’re transfusing—packed red cells—is quite different from whole blood. A study we reviewed highlighted some surprising statistics about the contents of packed red cells, including a pH of 6.79, a potassium level of 20, and a lactate level of 9.4. These figures reveal that packed red cells are far from the idealized image of whole blood.

The metabolic implications of these characteristics are significant, particularly in the context of massive transfusions. For instance, packed red cells have low levels of 2,3-DPG, which affects their ability to release oxygen to tissues. This raises important questions about how we use blood in trauma resuscitation and whether our current practices are truly optimal.

There’s also an ongoing pre-hospital trial in the UK, known as the RePHILL trial, which is examining the outcomes of patients randomized to receive either blood or no blood in pre-hospital settings. The results of this trial are eagerly anticipated and could challenge the assumption that blood is always better. This could lead to more nuanced transfusion practices in the future.

The Future of Diagnostics: Insights from Rick Body

Finally, we explored the future of diagnostics with insights from Rick Body. His presentation, originally given at the St Emlyn’s Live conference, offers a compelling vision of where diagnostics in the ED is heading. With the rise of machine learning, artificial intelligence (AI), and personalized diagnostics, the landscape of emergency medicine is rapidly evolving.

These technologies are already being integrated into diagnostic processes, but they bring new challenges. The data generated by AI and machine learning can be complex, requiring a shift in how we interpret diagnostic results. We must move away from binary thinking and embrace a more nuanced understanding that includes probabilities, uncertainties, and complexities.

As emergency medicine professionals, we need to prepare for this shift by engaging with these new technologies and incorporating them into our clinical practice. The future of diagnostics is exciting, but it will require ongoing education and adaptation to fully harness its potential.

Conclusion

August 2019 was a month rich with insightful discussions and important research that continue to influence our practice in emergency medicine. From managing lower GI bleeding and the environmental impact of anaesthesia to the complexities of blood transfusions and the future of diagnostics, these topics highlight the diverse challenges and opportunities we face in the ED.

The St Emlyn’s blog and podcast aim to keep you informed and engaged with the latest developments in our field. This review has provided valuable insights that can be applied in your practice, helping you stay ahead in the ever-evolving landscape of emergency medicine. Stay tuned for more updates, and as always, feel free to share your thoughts and experiences with us. Until next time, take care and continue to push the boundaries of what’s possible in emergency medicine.

 

St Emlyn’s July 2019: Key Highlights

Welcome back to St Emlyn’s, where we continue to share the latest insights, discussions, and advancements in emergency medicine. July 2019 was particularly rich in content, covering a wide range of topics from practical clinical advice to deeper reflections on the ethics and philosophy of emergency medicine. Here, we summarize the key points from the month’s posts, optimized for clarity and relevance.

Upcoming Events: Resuscitology Course and MSc in Emergency Medicine

Before diving into the content highlights, there are two important announcements:

Resuscitology Course – December 2019

On December 14th, 2019, the Resuscitology course will be held in Manchester. This course, led by Cliff Reid, offers an in-depth exploration of why certain resuscitation techniques work and how they can be improved in high-stakes scenarios. This is a must-attend for anyone involved in emergency or critical care. Registration details are available on our blog.

MSc in Emergency Medicine – 2019-2020 Cohort

Recruitment is now open for the 2019-2020 cohort of the MSc in Emergency Medicine. This three-year online program, available to both doctors and nurses, offers an advanced curriculum in emergency medicine. Alumni like Janus Bae, Alan Grace, and Natalie May have found it immensely beneficial. By 2020, we hope to extend the program to paramedics as well, broadening its reach and impact.

July 2019 Blog Highlights

This month’s content ranged from clinical insights and research updates to philosophical discussions about the practice of emergency medicine.

Disaster Medicine in Pakistan: Lessons Learned

Zaf Kasim, now practicing in the United States, and Rashid Akhil from Pakistan collaborated on a blog post discussing the management of natural disasters, terrorist attacks, and major incidents in Pakistan. Zaf, who trained with us in Verchester, has become an authority in endovascular resuscitation, REBOA, and ECMO.

This post sheds light on the expertise developed by medical professionals in Pakistan, particularly in response to large-scale disasters like the 2005 Kashmir earthquake. It’s a crucial read for anyone interested in global health or disaster medicine, as it demonstrates how effective disaster response systems can be developed even in resource-limited settings.

Managing Major GI Hemorrhage: Practical Insights

Chris Gray revisited a talk he gave at the St Emlyn’s Live Conference, focusing on the challenges of managing major gastrointestinal (GI) hemorrhage. Patients presenting with significant upper or lower GI bleeds pose unique challenges, particularly regarding airway management.

Chris offers practical advice, emphasizing the importance of resuscitating before intubation and considering video laryngoscopy in difficult cases. The post also highlights the SALAD (Suction Assisted Laryngoscopy and Airway Decontamination) technique, which is particularly useful in managing patients with large amounts of gastric contents.

Additionally, Chris touches on the use of PPIs, tranexamic acid (TXA), and terlipressin, although he advises caution until more evidence is available. The ongoing HALT-IT trial in the UK, investigating TXA in GI bleeds, is something to watch closely.

Listeriosis: A Rare but Serious Infection

Listeriosis, though uncommon, can have severe consequences, particularly for vulnerable populations like the elderly, pregnant women, newborns, and the immunocompromised. This blog post was prompted by a recent outbreak in the UK linked to contaminated hospital food.

The post emphasizes the importance of considering listeriosis in differential diagnoses, particularly for patients presenting with unexplained gastrointestinal symptoms. Blood cultures are essential for diagnosis, making it important to include them in the workup for high-risk patients. Early diagnosis is key to improving outcomes in these cases.

The Procedure Paradox: Ethical Reflections in Emergency Medicine

“The Great Day Paradox” delves into the ethical and emotional challenges of emergency medicine. Inspired by a talk at the Don’t Forget the Bubbles conference, this post explores the contrast between the excitement clinicians feel during life-saving procedures and the often devastating impact these events have on patients.

The post encourages clinicians to reflect on their motivations and maintain a patient-centered approach. Drawing on the teachings of John Hinds, it emphasizes that every procedure should be justified by both clinical need and appropriateness for the patient. This blog is a reminder of the importance of balancing clinical enthusiasm with compassion and ethical care.

Inferior Vena Cava Filters in Major Trauma: An Evidence-Based Review

Rich Carden reviewed the use of inferior vena cava (IVC) filters in major trauma patients, a topic that has been debated for years. IVC filters are intended to prevent pulmonary embolism (PE) in high-risk patients, such as those with significant lower limb or pelvic fractures.

Rich discusses a recent randomized controlled trial published in the New England Journal of Medicine, which found that early prophylactic use of IVC filters did not reduce the incidence of symptomatic pulmonary embolism or death at 90 days. This finding suggests that IVC filters should not be used routinely in major trauma patients, though there may be specific cases where they are warranted.

Psychological Performance in the Resus Room: Insights from Texas

Ashley Leibig’s presentation at St Emlyn’s Live focused on psychological performance in the resus room, drawing on her experience with StarFlight in Texas. Her blog post explores key concepts such as human factors, crew resource management, and self-awareness in high-pressure situations.

Ashley’s practical advice on managing oneself, the team, and the environment in emergency medicine is invaluable. This post is essential reading for anyone looking to improve their performance under pressure, whether in emergency medicine or other high-stress fields.

The Resuscitative Care Unit: A New Model for Emergency Departments

The concept of the resuscitative care unit (RCU) or ED-based critical care units was the focus of our final post of the month. Inspired by a paper published in the Emergency Medicine Journal (EMJ), this blog discusses the idea of creating RCUs to serve as a bridge between the emergency department and intensive care.

RCUs are proposed as a solution for managing critically ill patients who require short-term intensive care but may not need full ICU admission. The post also references a JAMA study showing that ED-based ICUs can improve survival rates for critically ill patients. As emergency departments continue to evolve, integrating critical care capabilities is becoming increasingly important.

Conclusion

July 2019 was a month filled with rich, varied content at St Emlyn’s, offering practical advice, research updates, and philosophical reflections on emergency medicine. Whether you’re interested in disaster management, GI haemorrhage, or the ethical challenges of our profession, this month’s highlights provide valuable insights.

We encourage you to engage with our content, share your thoughts, and continue learning. Don’t forget to check out our upcoming events, including the Resuscitology course and the MSc in Emergency Medicine. If you find our content valuable, please consider supporting us through a small donation to help keep St Emlyn’s free and accessible to all.

Thank you for being part of the St Emlyn’s community. We look forward to bringing you more valuable content in the coming months.

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

 

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.

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

 

St. Emlyn's Podcast: Key Insights from May in Emergency Medicine

As we transition into the warmer months, it's an opportune time to reflect on recent discussions and developments within the field of emergency medicine, particularly those highlighted in the latest episode of the St. Emlyn's podcast. This episode covered a wide range of topics, from workplace safety to advancements in pediatric care and innovative approaches in patient management. Below is a comprehensive summary of the key points discussed.

Workplace Safety: A Pressing Concern

The podcast began with a reflection on a recent violent incident at Newham Emergency Department (ED), which served as a stark reminder of the dangers healthcare professionals face daily. Emergency departments, by their very nature, are open and accessible, making them vulnerable to violent incidents. This recent attack has prompted a nationwide reassessment of safety measures, with many EDs enhancing their protocols to protect staff.

The conversation emphasized that violence in the workplace should never be normalized. It’s crucial that healthcare professionals feel safe and supported in their working environment. Leadership within departments plays a critical role in this, not only by implementing robust safety protocols but also by fostering a culture of solidarity and mutual support among staff. The incident at Newham underscores the need for constant vigilance and proactive measures to ensure the safety of everyone working in emergency medicine.

Leadership in Education: Simon Carley’s New Role

In more positive news, Simon Carley’s recent appointment as the CPD (Continuing Professional Development) lead for the college was discussed. This role is a significant milestone, not just for Simon but also for the integration of modern educational approaches within formal medical education. Simon’s involvement with St. Emlyn's has long been focused on innovative, social media-driven education, and this new role offers an opportunity to bring these methods into a broader educational framework.

The appointment highlights the value of combining traditional education with the dynamic, accessible formats offered by the #FOAMed (Free Open Access Meducation) community. It’s a recognition that medical education can benefit from new perspectives and that the integration of these ideas can enhance the learning experiences for healthcare professionals.

Pediatric Status Epilepticus: Evaluating Second-Line Agents

The discussion moved to a detailed analysis of pediatric status epilepticus, focusing on the findings from two key trials: the Eclipse trial and the ConSEPT trial. These studies compared the efficacy of levetiracetam (Keppra) and phenytoin as second-line agents for stopping seizures in children.

The trials found no significant difference between the two drugs in terms of their effectiveness, which has led to debate within the medical community about whether to switch from phenytoin to levetiracetam. While levetiracetam is perceived as easier to administer and safer, the lack of a clear superiority has left the decision somewhat open. However, the ease of use and safety profile of levetiracetam make it an appealing option, and some institutions are considering making the switch.

For clinicians, the takeaway is that while both drugs are viable options, the choice may ultimately come down to individual preferences and institutional protocols. The trials underscore the importance of continuous evaluation of treatment options, particularly in complex cases like pediatric seizures.

Understanding Clinical Trials: The Importance of Statistical Literacy

Simon Carley also highlighted the importance of understanding the statistical nuances in clinical trials, particularly the difference between demonstrating a difference between treatments and establishing their equivalence. This distinction is crucial for accurately interpreting research findings and making informed clinical decisions.

The discussion emphasized that clinicians must be cautious in how they interpret trial results, particularly when it comes to determining whether treatments are genuinely equivalent or if the lack of a significant difference merely reflects the study’s design. This level of critical appraisal is essential for ensuring that new research is applied correctly in clinical practice.

Prolonged Field Care in the ED: Learning from Military Medicine

Another topic discussed was prolonged field care, a concept borrowed from military medicine that is becoming increasingly relevant in emergency departments due to overcrowding and delays. Rich Carden introduced the HITMAN mnemonic—Hygiene and Hydration, Infection, Tubes, Medication, Analgesia, and Nutrition—as a framework for managing patients who are stuck in the ED for extended periods.

The HITMAN approach ensures that patients' fundamental needs are met even when resources are stretched. This method helps prevent complications and improves patient outcomes, even in less-than-ideal conditions. The approach is particularly relevant in today’s healthcare environment, where EDs are often overwhelmed and patients may wait longer than usual for admission or transfer.

Atrial Fibrillation: Reassessing Cardioversion Strategies

Atrial fibrillation (AF) management was another key topic. A recent study in the New England Journal of Medicine compared immediate cardioversion with a wait-and-see approach in patients with new-onset AF. The study found that a wait-and-see approach was non-inferior to immediate cardioversion, with 69% of patients in the wait-and-see group spontaneously cardioverting within 48 hours.

This finding challenges the traditional approach of immediate cardioversion and suggests that in many cases, a more conservative approach may be just as effective. However, the decision should be made through shared decision-making with the patient, taking into account their preferences and the specific circumstances of their condition. This patient-centered approach ensures that treatment decisions are made collaboratively and with the patient’s best interests in mind.

Traumatic Cardiac Arrest: Reevaluating Chest Compressions

The podcast also touched on the evolving management of traumatic cardiac arrest, particularly the role of chest compressions. Recent studies, including one involving porcine models, suggest that in cases of hypovolemic traumatic cardiac arrest, chest compressions may not be beneficial and could even be harmful. Instead, the focus should be on addressing the underlying cause, such as restoring circulating volume.

This shift in practice highlights the importance of understanding the specific etiology of cardiac arrest and tailoring resuscitation efforts accordingly. Communicating these changes to the entire resuscitation team is crucial, as there may be resistance to deviating from traditional protocols. Ensuring that everyone is on the same page and understands the rationale behind the approach is key to successful implementation.

Virtual Reality in Pain Management: An Emerging Tool

Virtual reality (VR) is emerging as a promising tool in pain management, particularly in pediatric patients undergoing painful procedures. A recent study discussed in the podcast found that children who used VR experienced less distress during procedures compared to those who received standard care.

VR offers an innovative, accessible method for managing pain and anxiety, and its use is likely to expand in the coming years. The ability to create immersive environments that distract patients during procedures has the potential to improve patient experiences and outcomes, not just in children but potentially in adults as well.

The Power of Peer Review: Enhancing Clinical Practice

Finally, Simon Carley discussed the importance of peer review in clinical practice. Peer review is a valuable tool for continuous improvement, allowing clinicians to receive feedback from colleagues on their performance. While it can be challenging to create a culture where feedback is welcomed and constructive, the benefits are significant.

Peer review helps clinicians avoid complacency, stay up-to-date with best practices, and continually refine their skills. It’s a simple, cost-effective way to ensure that healthcare professionals are delivering the highest standard of care. Creating a supportive environment where feedback is seen as an opportunity for growth rather than criticism is essential for the success of peer review initiatives.

Conclusion

The discussions in this month’s St. Emlyn's podcast highlight the complexities and challenges of working in emergency medicine, from ensuring workplace safety to staying current with evolving practices. By engaging with new research, embracing innovative tools like virtual reality, and fostering a culture of continuous improvement through peer review, we can continue to advance the field and improve patient care. As always, the St. Emlyn's blog and podcast remain valuable resources for staying informed and connected with the latest developments in emergency medicine.

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!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

Understanding P Values: A Comprehensive Guide for Clinicians

Welcome to St Emlyn's blog, where we delve into the complex world of P values—a crucial element in medical research. For emergency medicine clinicians, understanding P values is essential for interpreting study results and applying them effectively in clinical practice. This post aims to demystify P values and enhance your critical appraisal skills.

What Are P Values?

P values are a measure of the probability that an observed difference could have occurred just by chance if the null hypothesis were true. The null hypothesis generally states that there is no difference between two treatments or interventions. Thus, a P value helps us determine whether the observed data is consistent with this hypothesis.

The Null Hypothesis and Significance Testing

To grasp P values fully, we start with the null hypothesis. In any trial, we begin with the premise that there is no difference between the treatments being tested. Our goal is to test this null hypothesis and ideally disprove it, a process known as significance testing.

When we calculate a P value, we express the probability of obtaining a result as extreme as the one observed, assuming the null hypothesis is true. For instance, a P value of 0.05 suggests a 5% chance that the observed difference is due to random variation alone.

The Magic of 0.05

The threshold of 0.05 has become a benchmark in research. A P value below this threshold is often considered statistically significant, while one above is not. However, this binary approach oversimplifies statistical analysis. The figure 0.05 is arbitrary and does not imply that results just above or below this threshold are vastly different in terms of practical significance.

Clinical vs. Statistical Significance

Distinguishing between statistical significance and clinical significance is crucial. A statistically significant result with a very small P value may not always translate into clinical importance. For example, a large study might find that a new treatment reduces blood pressure by 0.5 millimetres of mercury with a P value of 0.001. While statistically significant, such a small reduction may not be clinically relevant.

Conversely, a clinically significant finding might not reach the strict threshold of statistical significance, particularly in smaller studies. Therefore, it's essential to consider both the magnitude of the effect and its practical implications in clinical practice.

The Fragility Index

The fragility index is an alternative measure that addresses some limitations of P values. It calculates the number of events that would need to change to alter the study's results from statistically significant to non-significant. This index provides insight into the robustness of the findings. Surprisingly, even large trials can have a low fragility index, indicating that their results hinge on a small number of events.

Moving Beyond 0.05

Recognizing the limitations of the 0.05 threshold, some researchers advocate for more stringent criteria, such as a P value of 0.02, particularly in large randomized controlled trials (RCTs). This approach aims to reduce the likelihood of false-positive results and improve the reliability of findings. However, it also raises the bar for demonstrating the efficacy of new treatments, which can be a double-edged sword.

Multiple Testing and Bonferroni Adjustment

A significant challenge in research is multiple testing. Conducting numerous statistical tests increases the probability of finding at least one significant result purely by chance. This issue is particularly relevant in exploratory studies where multiple outcomes are assessed.

One method to address this problem is the Bonferroni adjustment, which adjusts the significance threshold based on the number of tests performed. While this approach helps control the risk of false positives, it can be overly conservative and reduce the power to detect true effects. Therefore, it should be used judiciously.

Interim Analysis in Clinical Trials

Interim analysis is a crucial aspect of clinical trials, allowing researchers to assess the effectiveness or harm of an intervention before the study's completion. However, performing multiple interim analyses can increase the risk of false-positive findings. To mitigate this risk, researchers use techniques like P value spending functions, which adjust the significance threshold for each interim analysis.

Additionally, the number of interim analyses should be limited and pre-specified in the study protocol. This ensures that decisions to stop a trial early are based on robust evidence and not on arbitrary or opportunistic analyses.

Effect Size and Confidence Intervals

P values alone do not provide a complete picture of the study results. It's equally important to consider the effect size, which measures the magnitude of the difference between treatments. A small P value might indicate statistical significance, but without a substantial effect size, the clinical relevance of the finding remains questionable.

Confidence intervals (CIs) complement P values by providing a range within which the true effect size is likely to lie. A 95% CI means that if the study were repeated multiple times, 95% of the calculated intervals would contain the true effect size. CIs offer valuable context for interpreting P values and understanding the precision of the estimated effect.

Practical Tips for Interpreting P Values

1. Understand the Null Hypothesis: Always start with a clear understanding of the null hypothesis and what the study aims to test.
2. Look Beyond the P Value: Consider the effect size, confidence intervals, and clinical significance of the findings.
3. Be Cautious with Multiple Testing: Recognize the increased risk of false positives with multiple comparisons and apply appropriate adjustments.
4. Assess the Fragility Index: Use the fragility index to gauge the robustness of the study's findings.
5. Consider Interim Analysis: Ensure that interim analyses are pre-planned and interpreted with caution to avoid bias.
6. Question the Threshold: Remember that the 0.05 threshold is not a magic number. Interpret P values in the context of the study design, sample size, and practical implications.

Conclusion

P values are a fundamental aspect of medical research, but their interpretation requires a nuanced understanding. By considering the null hypothesis, clinical significance, effect size, and confidence intervals, we can make more informed decisions based on the data. As emergency medicine clinicians, our goal is to apply research findings judiciously to improve patient care.

We hope this deep dive into P values has clarified their role and limitations in research. Remember, the journey to mastering statistical concepts is ongoing, and continuous learning is key. If you have any questions or thoughts, please share them in the comments below. Happy appraising, and stay curious!

St. Emlyn's January Roundup: Key Insights and Innovations

Hello and welcome to the St. Emlyn’s Podcast. I’m Simon Carley, joined by Rick Body. Today, we’re bringing you our January roundup, sharing the most intriguing and impactful content we've covered this month. From reflecting on 2018 to exploring new guidelines and innovations in emergency medicine, we have a lot to discuss. Let’s dive in!

Reflecting on 2018: Transformational Reads and Achievements

As we started January, we reflected on 2018, a year filled with significant achievements and insights. One standout discussion was our review of key books that left a lasting impact. A personal favorite of mine is "Why We Sleep" by Matthew Walker. This book has been transformational for me, influencing how I live and advise others on health, well-being, and performance. The insights on sleep’s importance in education, creativity, and overall health are profound.

Rick, did anything from our 2018 review resonate with you?

Rick Body: Absolutely, Simon. The variety of books we discussed was impressive. It was enlightening to hear about others' achievements in 2018 and their goals for 2019. This exercise really focused my mind on what I hope to achieve this year.

Goals for 2019: Innovations and Personal Aspirations

As we moved from reflections to aspirations, we set our sights on exciting projects for 2019. One major highlight is the AI incubator for emergency care. This initiative aims to support academic careers and foster partnerships between data and industry to enhance medical technologies. It’s an exhilarating time for advancements in emergency care.

Rick is incredibly busy with groundbreaking work, particularly in diagnostics in Manchester. His research and speaking engagements are making waves in the medical community. For more details on these projects, check out the blog where all the information is comprehensively covered.

New Year’s Resolutions: Insights from Liz Crowe

We explored New Year’s resolutions with Liz Crowe, who offered a fresh perspective on well-being and resolutions. Instead of focusing on all-or-nothing goals, Liz suggests starting small and seeking rewards rather than punishments. This approach makes significant lifestyle changes more manageable and sustainable. Committing to resolutions publicly or with a friend can enhance accountability and success.

Rick, do you have any New Year’s resolutions?

Rick Body: It’s challenging to pinpoint one or two, but Liz’s advice on avoiding binary thinking is crucial. Recognizing progress rather than dwelling on setbacks can make a big difference.

Tetanus Guidelines: New Insights and Practical Applications

In January, we delved into updated tetanus guidelines, highlighting significant changes. Previously, a single booster in your early 20s was deemed sufficient, but the new guidelines recommend a 10-year booster. This change stems from the recognition that immunity wanes over time. Interestingly, point-of-care testing is now available to detect active tetanus immunization, allowing for more tailored booster decisions.

These updates are crucial for emergency physicians to ensure compliance with current standards and provide optimal patient care. The blog post simplifies these guidelines, making them accessible and easy to understand.

Excellence in Emergency Medicine: Claire Richmond’s Contributions

We featured Claire Richmond, a hero in the emergency medicine community. Claire, who works with Sydney HEMS, delivered an inspiring keynote at the St. Emlyn’s live conference. Her talk focused on excellence, performance, training, and development in retrieval medicine. She emphasized the importance of honesty, feedback, and continuous improvement.

For those aspiring to achieve self-actualization in emergency medicine, Claire’s insights are invaluable. We’ve shared the video and podcast of her talk, and we highly recommend checking them out.

Prognosticating Cardiac Arrest Outcomes: Dan Horner’s Research

Another highlight of January was Professor Dan Horner’s discussion on serum neurofilament light chains, a promising tool for prognosticating cardiac arrest outcomes. This research, stemming from the TTM trial, suggests that these biomarkers can provide early predictions about patient outcomes. Early identification of patients likely to have poor neurological outcomes can significantly impact family discussions, treatment decisions, and overall management.

This research is groundbreaking and holds potential for future clinical applications, although it’s not yet ready for immediate practice.

Celebrating Evidence-Based Medicine: Critical Appraisal E-Book

We’re incredibly proud of our journal club series at St. Emlyn’s, which advocates for evidence-based medicine. This series highlights the latest research, making it accessible and understandable. To celebrate the contributions over the past year, we’ve compiled an e-book available for free download. This resource is a testament to our commitment to advancing medical knowledge and practice.

Pre-Medication for Ketamine Sedation: Exploring New Research

One of the intriguing studies we covered this month examined pre-medication with midazolam or haloperidol for ketamine sedation. The randomized control trial suggested that pre-medication could reduce complications like abnormal behaviors and emergence phenomena. However, it also increased recovery time, requiring more resources and nursing time.

While the findings are interesting, they haven’t convinced us to change our current practice. However, it’s essential to stay informed about such research to make informed decisions in clinical practice.

HEMS and Traumatic Cardiac Arrest: Evaluating Outcomes

We also discussed the role of HEMS in improving outcomes for traumatic cardiac arrest. The study from the UK highlighted the high-level interventions provided by HEMS teams. However, it raised questions about the overall impact on patient survival. Of the 263 patients attended, only seven survived, and all had achieved ROSC before HEMS arrival. This data suggests that while HEMS interventions are critical, their direct impact on survival needs further evaluation.

This topic is sure to spark debate, and we appreciate the transparency of HEMS services in sharing their data and encouraging open discussions.

Looking Ahead: Plans for the Future

As we wrap up January, we’re excited about the plans for the coming months. Simon is heading to Jeddah for a significant event, and we’re considering hosting another St. Emlyn’s live conference and teaching course. We’re exploring innovative formats for medical conferences and welcome your ideas on how we can make these events even more impactful.

Support St. Emlyn’s: Keeping Education Free and Accessible

Since 2012, we’ve funded the blog and podcast out of our own pockets, but as our audience has grown, so have the costs. If you find our content valuable, please consider making a small donation or subscribing for regular contributions. Your support helps us keep St. Emlyn’s free and accessible to all.

Thank you for your time and continued support. Stay tuned for more updates, and as always, enjoy your emergency medicine practice and take care!

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

 

St Emlyn's November 2018 Review: Key Highlights and Insights

Hello and welcome to the St Emlyn's Podcast and blog. I'm Simon Carley, and I'll be guiding you through the exciting topics and developments we've covered on the blog in November 2018. From leadership insights to groundbreaking medical research, this month has been incredibly informative. Let's dive into the highlights!

Leadership Insights from the FIX Conference

We begin our review in New York, where Natalie May attended the FIX (FeminEM) Conference. In her second post about this event, Natalie explores profound themes, particularly around leadership and motivation in the medical field.

Key Takeaways on Leadership and Motivation

Jennifer Walthall's talk emphasized the importance of acting within the system to drive change. When joining an organization that may not align with your values, you can either work within the system to improve it or fight from the outside. Walthall advocates for influencing change from within, suggesting that once embedded, you can effectively drive improvements.

Lara Goldstein's session on leadership identified four critical attributes of a good leader:

1. Listening: Truly understanding your team.
2. Recognizing the Impact of Small Actions: Little things add up.
3. Conflict Management: Not everyone will like you, and that's okay.
4. Gratitude, Kindness, and Decency: Core values that should guide every leader.

Natalie's detailed reflections on the FIX Conference are a must-read for those interested in these themes. Attending FIX in 2019 should be on your list if possible!

POLAR Trial: New Insights into Hypothermia Post-Brain Injury

Dan Horner analyzed the POLAR trial in one of our journal club posts. The POLAR trial is a significant randomized control trial investigating the effects of hypothermia in the early stages after a brain injury. This study follows the Eurotherm trial, which explored hypothermia's role in patients with severe brain injuries in the ICU.

What the POLAR Trial Reveals

The POLAR trial involved 511 patients with severe brain injuries, randomized to either hypothermia (cooling to 33-35°C) or maintaining normothermia for 72 hours. Despite strong pathophysiological evidence supporting hypothermia, the trial found no significant difference in outcomes after six months. Initial results suggest that routine hypothermia for early-stage brain injury might not be beneficial, but long-term data follow-up is crucial. This trial, published in JAMA, is essential reading for anyone involved in emergency medicine or critical care.

The Case for Whole Blood Transfusion in Trauma: Insights from Zaf Qasim

Zaf Qasim, a former Manchester trainee now making waves in the US, contributed an enlightening post on the use of whole blood in trauma resuscitation. This approach, which makes intuitive sense—replacing lost whole blood with whole blood—contrasts with the UK practice of separating blood into components for transfusion.

Advantages of Whole Blood Transfusion

Zaf argues that whole blood could simplify and improve trauma care, reducing the time and complexity of reconstituting blood components in the body. Although not yet standard in the UK, this method is gaining traction in places like London HEMS and various European centers. As data continues to emerge, this could revolutionize trauma care, harkening back to practices from the Second World War and Vietnam.

Challenging the Use of "Sexy" in Clinical Medicine

Natalie May returns with a provocative post challenging the use of the term "sexy" in clinical medicine, especially in resuscitation-related specialties. Often used to describe procedures or equipment, this term can inadvertently perpetuate gender biases and undermine professionalism.

Redefining Professional Language

Natalie, supported by her husband Oli May's humorous yet insightful critique, urges us to reconsider such language. The term "sexy" in a medical context is not a compliment and can contribute to a culture that sexualizes women in the workplace. This reflection is especially relevant for departments striving to maintain professionalism and inclusivity.

Understanding Cognitive Load Theory with Nick Smith

In the realm of medical education, Nick Smith's debut blog post introduces us to cognitive load theory. As a clinical educator in Manchester, Nick explores how intrinsic, extrinsic, and germane cognitive loads affect learning and teaching.

Applying Cognitive Load Theory in Medical Education

Nick's post is a valuable resource for educators aiming to optimize their teaching strategies. By understanding and managing cognitive load, we can create more effective and supportive learning environments for our trainees. This post is part of a broader series on educational theories that are crucial for medical educators.

Elective Experience in South Africa: Lessons from Claire Bromley

Medical student Claire Bromley shares her transformative elective experience at Mitchell's Plain with the BAD EM team. Working with leaders like Katya Evans and Craig Wylie, Claire's reflections offer deep insights into the challenges and rewards of emergency medicine in South Africa.

Bridging UK Training with South African Realities

Claire highlights the stark differences between UK and South African healthcare systems, particularly the intense workload and resource constraints in the public sector. Her experience underscores the importance of preparation, respect, and adaptability for anyone considering working in a different health economy.

Promoting Diversity in the Emergency Department

Natalie May's final post for November reflects on promoting diversity and inclusivity in the emergency department. She emphasizes that the ED is unique in its diversity, seeing patients from all walks of life.

Embracing and Understanding Diversity

Natalie advocates for a broader understanding of diversity beyond ethnicity, including gender, disability, and sexual orientation. Her insights are essential for ED professionals committed to providing equitable care and fostering an inclusive environment.

Learning in the Social Age: Embracing Medutainment

I had the pleasure of discussing "Learning in the Social Age" at the Emerge 10 conference in Scotland. This presentation, supported by a blog post, explores how the internet and social media are transforming medical education.

The Impact of Medutainment

We are now competing on a global scale as educators, with learners accessing information from various sources worldwide. This shift necessitates embracing new methods of engagement, ensuring our teaching remains relevant and impactful.

Beyond ALS: Innovations in Cardiac Arrest Management

We wrapped up November with a highlight from St Emlyn's Live, featuring Salim Rezaie from the RebelEM blog and podcast. Salim's presentation on "Beyond ALS" challenges us to rethink cardiac arrest management, focusing on advanced techniques and evidence-based practices.

Advancing Cardiac Arrest Protocols

Salim's talk covers crucial aspects such as minimizing shock pauses, effective adrenaline administration, and optimizing IV/IO access. For anyone serious about improving their ALS skills, this blog, podcast, and accompanying videos are indispensable resources.

Looking Ahead

November was a whirlwind of activity and learning at St Emlyn's, and we have plenty more in store for December. As we approach the holiday season, we hope you find time to explore these posts and integrate their lessons into your practice. Thank you for being part of the St Emlyn's community, and we look forward to continuing this journey of learning and improvement together.

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/ 

Welcome to the St Emlyn's Podcast: October 2018 Highlights

Hello and welcome to this St Emlyn’s podcast. My name is Simon Carley, and today I'm thrilled to take you through all the exciting events and updates we've been involved in this October 2018. This month has been bustling with activities, learning opportunities, and insightful experiences that we are eager to share with you.

The Inaugural St Emlyn's Live Conference

We kicked off October with a bang by hosting the first-ever St Emlyn’s live conference in Manchester. This landmark event brought together a diverse group of delegates and speakers, creating a vibrant atmosphere of learning and collaboration. The focus was on the four pillars of emergency medicine as we see it at St Emlyn’s:

1. Emergency and Spades Medicine
2. Excellence in Critical Care
3. Wellbeing
4. The Philosophy of Emergency Medicine

We had an incredible day filled with discussions on why we do what we do and how we can continue to improve our practices. The energy and enthusiasm from the participants were palpable, and we are excited to share all the presentations and insights from this event over the coming months. Stay tuned to our blog and media channels for updates.

Five Ways to Improve Your Resuscitation Skills

One of the highlights from the conference was my presentation on "Five Things You Can Do to Improve Your Resuscitation." Although the video is not yet released, the blog post is available, and I want to give you a sneak peek into some practical tips that can make a significant difference in your practice.

1. The Zero Point Survey

The zero-point survey is a concept introduced by Cliff Reid, emphasizing the importance of preparation before patient contact. Your resuscitation process should begin the moment you hear about the patient, not when you meet them. This preparatory phase includes ensuring your physical readiness, team coordination, and environment setup.

Key Steps:

• Self-preparation: Ensure you are physically and mentally ready.
• Team readiness: Identify team roles and confirm competency.
• Environmental setup: Check equipment, ensure visibility, and prepare necessary tools.

2. 10 in 10

The 10 in 10 concept involves taking 10 seconds every 10 minutes during a resuscitation to reassess and communicate with your team. This regular pause helps in reappraising the situation and updating your mental models, ensuring everyone is on the same page.

3. Fly the Patient and Then Think

In emergency medicine, drawing from aviation, one person should focus on maintaining the basics (aviate) while another makes higher-level decisions (navigate and communicate). In a resuscitation scenario, one team member should follow the algorithm and manage immediate life support, while another considers broader strategies and decisions.

4. Peer Review

Peer review is essential for growth and self-awareness. Having someone observe your practice and provide feedback can uncover blind spots and improve your performance. This process benefits both the observer and the observed, fostering a culture of continuous improvement.

5. Hot Debriefs

Adopted from the Edinburgh emergency departments, hot debriefs are quick, five-minute sessions immediately after an event. This practice allows teams to reflect on their performance, discuss what went well, and identify areas for improvement. Implementing hot debriefs can enhance team dynamics and overall performance.

Enhancing Education in Busy Environments

In another educational blog this month, I discussed how to teach and learn effectively in a stretched environment, drawing from a talk at the Royal Society of Medicine in London. Contrary to popular belief, being busy does not preclude learning opportunities. Data from the GMC survey indicates that exposure to relevant cases and support in learning significantly impact trainee satisfaction, rather than workload alone.

Effective Teaching Strategies:

1. Post-it Polls: Write down interesting cases or learning points throughout the day and display them on a board for everyone to see and discuss.
2. FOAMed Prescriptions: Share relevant online resources with trainees to reinforce learning through spaced repetition.
3. Social Media Utilization: Use platforms like WhatsApp and message boards to discuss cases and share insights while maintaining confidentiality.

Cricoid Pressure and RSI: Ongoing Debates

We revisited the controversial topic of cricoid pressure in rapid sequence intubation (RSI) with a journal club post. Despite longstanding debates, recent evidence, including a study published in JAMA, suggests that cricoid pressure may not significantly impact laryngoscopy success rates. However, it might still be beneficial in specific high-risk scenarios. The key takeaway is to make informed decisions based on the latest evidence rather than following traditional practices blindly.

FemInEm Conference Highlights

Natalie May attended the FemInEm conference in New York and shared her insights in a detailed blog post. The FemInEm group focuses on promoting gender equity in emergency medicine but offers valuable resources for all practitioners. Natalie’s presentation on avoiding the use of the word "sexy" in emergency medicine was particularly thought-provoking. Stay tuned for more from this inspiring conference.

Pursuit of Excellence in Emergency Medicine

Natalie May also delivered a keynote presentation at St Emlyn’s Live on the pursuit of excellence. Drawing from her experiences in the UK and Australia, she emphasized the importance of continuous learning and collaboration with colleagues. Her talk highlighted that achieving self-actualization in emergency medicine requires support from a dedicated team, reflection, and a commitment to improvement.

Addressing PTSD in Emergency Medicine

Rusty Carroll continued his series on PTSD, exploring novel therapies such as eye movement desensitization and reprocessing (EMDR), now approved by NICE. This installment provides valuable insights for those dealing with PTSD, offering hope and practical solutions.

Looking Ahead

As we wrap up October, we have an array of exciting content lined up for November and beyond. We will be releasing more materials from St Emlyn’s Live and sharing insights from our Teaching Co-Op course. The course was a fantastic experience, and we are considering hosting it again due to popular demand.

In the meantime, we encourage you to engage with our blogs, videos, and social media channels. Join us in our journey to improve emergency medicine practices and enhance patient care. Stay connected, stay curious, and enjoy your adventures here at St Emlyn’s.

Thank you for being a part of the St Emlyn’s community!

By following these tips and strategies, you can optimize your practice, foster a culture of continuous learning, and improve patient outcomes. Don’t forget to subscribe to our blog and podcast for the latest updates and insights from the world of emergency medicine.

 

 

 

 

Monthly Update from St. Emlyn’s: Insights into Emergency Medicine

Welcome to the St. Emlyn’s podcast blog! I’m Ian Beardsell, and alongside Simon Cully, we're here to bring you our monthly update. This post will delve into February's content, upcoming events, and the latest discussions in emergency medicine.

Winter Challenges and Patient Updates

Winter has been relentless this year, and we're still feeling its impact. The influx of patients hasn't slowed down, and our departments are buzzing with activity. Up in Manchester, we continue to see a high volume of patients, while down south, the weather has been kinder, though no less busy. As a Yorkshireman, I can empathize with the challenges faced in the North. Hang in there, and let's get through these cold evenings together!

Upcoming Events: St. Emlyn’s Live and Teaching Course

Before diving into February's posts, let's talk about the exciting events we have lined up. This October, we're hosting the St. Emlyn’s Live conference and the Teaching Course in Manchester.

St. Emlyn’s Live Conference

The St. Emlyn’s Live conference is a one-day event focused on our philosophy's four pillars: clinical work, evidence-based medicine, wellbeing, and the philosophy of emergency medicine. With international speakers, this event promises to be an enriching experience for all attendees. Spaces are limited, so make sure to book your spot early via our website.

Teaching Course in Manchester

Following the conference, we have a three-day Teaching Course designed to develop you as an expert teacher in emergency medicine. This comprehensive course covers all aspects of teaching and is an excellent opportunity to enhance your skills. All bookings can be made through the St. Emlyn’s website.

Insights from February’s Blog Posts

February was a month rich with valuable insights and studies. Let's delve into some of the highlights:

Intranasal Ketamine and Fentanyl for Children

One of the standout studies we reviewed in February focused on the use of intranasal ketamine and fentanyl for managing pain in children. Pain management in pediatric patients is always challenging, especially when IV access is difficult. Traditionally, we've used intranasal diamorphine, but there's been a shift towards using intranasal ketamine and fentanyl, particularly in the US.

Study Overview

This randomized controlled trial compared 1 mg/kg of intranasal ketamine against 1.5 mcg/kg of intranasal fentanyl in children aged 4 to 17 with suspected isolated extremity fractures. The primary outcome was pain reduction, and both drugs performed similarly in this regard.

Side Effect Profiles

The key takeaway was the difference in side effect profiles. Ketamine is known to cause dysphoria, vomiting, and dizziness, while fentanyl has fewer unpleasant side effects. Therefore, fentanyl emerged as the preferred choice not because of superior pain relief but due to its more favourable side effect profile.

Practical Implications

The study underscores the importance of having a streamlined protocol for intranasal medications in emergency departments. While some departments might still use syringes, investing in mucosal atomizer devices can simplify administration and improve patient care.

Engaging Medical Students in Emergency Medicine

We had a guest blog from Claire Bromley, a medical student working with us in Manchester. Claire shared her experiences and insights into why she chose emergency medicine as a career, despite the occasional negativity she faced from other specialties.

Building a Career in Emergency Medicine

Claire's blog is an inspiring read for medical students considering a career in emergency medicine. She highlights the importance of engaging students in the department and ensuring they see the undifferentiated, unwell patients that characterize our specialty. Her experiences as a SMACC volunteer and her early involvement in FOAMed (Free Open Access Medical Education) are testaments to the value of early engagement and online education.

The Role of Educators

One of the significant challenges we face is balancing the educational needs of students with the operational demands of the department. However, investing time in student education is crucial. These students are our future colleagues, and their early exposure to emergency medicine can shape their career choices and prepare them for the challenges ahead.

Aromatherapy with Isopropyl Alcohol for Nausea

A fascinating study we reviewed involved the use of isopropyl alcohol for nausea relief. The concept of sniffing alcohol swabs to alleviate nausea isn't new, but this study provided robust evidence supporting its effectiveness.

Study Design and Results

The randomized controlled trial compared the effects of isopropyl alcohol sniffing to oral ondansetron in adult patients presenting with nausea in the emergency department. The results were surprising: patients who sniffed isopropyl alcohol swabs reported greater relief from nausea than those who took ondansetron.

Implementation Challenges

While the study's findings are promising, implementing this practice consistently in emergency departments can be challenging. Ensuring that alcohol swabs are readily available and that staff are trained to use them effectively is key. Additionally, clarifying whether a Patient Group Directive (PGD) is required for this intervention could streamline its adoption.

Reflections on Historical Practices

One of the lighter yet insightful pieces this month was a video from the 1970s showcasing a casualty department in Liverpool. Watching historical medical practices can be both amusing and educational, offering a perspective on how far we've come and what future generations might think of our current practices.

Educational Value

While humorous at times, the video also highlights the core principles of emergency medicine that remain unchanged. It reminds us of the importance of continuous learning and adaptation in our field.

Looking Ahead: SMACC 2019 and Beyond

As we look forward to the year ahead, we’re excited about the upcoming SMACC conference in Australia in 2019. Planning for study leave and participation in such international conferences is essential for continuous professional development. These events provide unparalleled opportunities for learning, networking, and sharing best practices.

Conclusion

February has been a month filled with valuable insights, studies, and preparations for future events. The emphasis on pain management in children, engaging medical students, and innovative approaches to nausea relief reflects our ongoing commitment to improving patient care and education in emergency medicine.

Natalie and Simon discuss reflections, e-books and life at Sydney HEMS. This week we have added Lorikeets in the background (Nat recorded at Coogee Bay in NSW). We think they sound cute so we've kept them in (or rather we could not edit them out).

S

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.

In this episode of the St Emlyn's podcast, Ian Beardsell and Simon Carley review the top 10 trauma papers of the year, highlighting key findings and their implications for trauma care. The selection includes significant studies published in high-profile journals such as The Lancet and the New England Journal of Medicine, offering valuable insights for healthcare professionals in emergency and trauma medicine.

1. Whole Body CT Scanning: REACT-2 Study

The REACT-2 study explored the impact of whole-body CT (WBCT) scanning on trauma patients, particularly its effect on mortality rates. The study involved 1400 patients and found no significant difference in mortality between those who received WBCT and those who underwent more selective CT scanning. The difference in radiation exposure was minimal, suggesting that WBCT's comprehensive imaging might be more beneficial than harmful, especially in elderly patients where missed injuries can complicate outcomes. This study reassures trauma team leaders that current scanning practices are appropriate and highlights the importance of a patient-centred approach based on clinical presentation.

2. Impact Brain Apnea (IBA)

Impact brain apnea, characterized by apnea and a catecholamine surge following a severe head blow, has been increasingly recognized in trauma care. The paper, co-authored by John Hines and Mark Wilson, provides a detailed explanation of IBA's pathophysiological mechanisms. This condition can lead to cardiac arrest if not promptly addressed, emphasizing the need for immediate intervention in cases of traumatic brain injury (TBI). Understanding IBA helps emergency care providers identify and treat potentially life-threatening conditions that may not be immediately apparent.

3. Decompressive Craniectomy for Raised ICP: RESCUE-ICP Trial

The RESCUE-ICP trial examined the outcomes of decompressive craniectomy in patients with refractory intracranial pressure (ICP) due to severe TBI. The study found that while the procedure increased survival rates, many survivors experienced significant disability. This raises ethical considerations about the quality of life post-intervention. The trial underscores the importance of informed consent and discussions about potential outcomes with patients' families, aligning treatment with patient values.

4. STITCH Trial: Surgery Timing for Intracranial Bleeds

The STITCH trial focused on the timing of surgical intervention in patients with traumatic intracranial bleeds. Although the trial faced recruitment challenges and was terminated early, results suggested better outcomes with early surgery. This finding, while not statistically conclusive, supports the notion that timely intervention can reduce mortality and improve recovery. Emergency physicians and neurosurgeons should consider these findings when deciding on surgical timing in TBI cases.

5. Traumatic Cardiac Arrest: Epidemiology and Outcomes

Using data from the Trauma Audit and Research Network (TARN), this study examined traumatic cardiac arrest (TCA) cases, revealing a 30-day survival rate of 7.5%. This rate, similar to medical cardiac arrests, challenges the perception that TCA is almost always fatal. The study highlights the importance of aggressive resuscitation efforts and underscores the need for ongoing training to retain skills in managing these rare but critical events.

6. Open vs. Closed Chest Compressions in TCA

The effectiveness of open chest (thoracotomy) versus closed chest compressions in TCA was explored, with findings indicating similar outcomes in terms of end-tidal CO2 levels, a marker for effective CPR. This challenges the notion that thoracotomy should always be performed in TCA cases. The study suggests that standard advanced life support (ALS) protocols may suffice in certain scenarios, especially where thoracotomy is not practical.

7. Rocuronium vs. Succinylcholine for RSI in Severe Brain Injury

The choice between rocuronium and succinylcholine for rapid sequence intubation (RSI) in severe brain injury remains debated. An observational study found no significant overall difference in mortality between the two drugs, though succinylcholine was associated with higher mortality in severe head injury cases. This suggests a possible preference for rocuronium in such scenarios, though the evidence is not strong enough to mandate a change in practice.

8. Intraosseous Needle Length in Obese Patients

As obesity becomes more prevalent, appropriate intraosseous (IO) needle length is crucial for effective vascular access. The study recommended using longer yellow IO needles for patients with a BMI over 43, as standard blue needles may not reach the marrow. This is particularly important in emergency situations where IV access is difficult, ensuring proper drug administration and preventing complications like compartment syndrome.

9. Optimal Site for Needle Decompression in Tension Pneumothorax

A systematic review recommended the anterior axillary line as the preferred site for needle decompression in tension pneumothorax, aligning with standard chest drain placement. The review also noted significant complication rates associated with needle decompression, suggesting that alternative methods like thoracostomy may be necessary in certain cases. This finding emphasizes the need for precise technique and careful consideration in managing tension pneumothorax.

10. Weekend Effect in Major Trauma Care

The study examined the "weekend effect" in major trauma care, finding no significant difference in mortality between weekend and weekday admissions. This suggests that well-resourced, consultant-led trauma care can provide consistent outcomes regardless of the day. The findings advocate for the 24/7 availability of senior emergency physicians and trauma teams, ensuring high-quality care at all times.

Conclusion

This year's top trauma papers provide valuable insights into current practices and emerging trends in trauma care. While there may not have been groundbreaking changes, the studies reinforce the importance of evidence-based decision-making, ongoing training, and ethical considerations in patient management. As the field evolves, staying informed about the latest research is crucial for improving patient outcomes and delivering high-quality trauma care. For further details and access to the studies, visit the Sentemlin site and related FOAMed resources.

 

 

 

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.

 

Summary of Selection Bias in Medical Research

Introduction

Selection bias is a critical issue in medical research that can undermine the validity of study findings. It occurs when there is a systematic difference between the study population and the broader population the research aims to represent. Understanding selection bias is essential for clinicians and researchers, as it can lead to questionable conclusions and affect clinical practice. This summary covers the definition of selection bias, its sources, and ways to mitigate it, along with a case study illustrating its impact.

What is Selection Bias?

Selection bias happens when the participants in a study do not accurately reflect the general population. This discrepancy can result from various factors, including how patients are selected, the setting of the study, and the timing of patient recruitment. Such biases can skew research results, making them less applicable to real-world situations. As medical professionals rely heavily on research to inform clinical decisions, recognizing and addressing selection bias is crucial.

Sources of Selection Bias

1. Study Environment

   The environment where a study is conducted can significantly influence patient selection. For instance, patients in a general practitioner's office might have a lower prevalence of serious conditions compared to those in an emergency department. Additionally, studies in specialized tertiary care centers often include patients with more severe or rare conditions, which may not represent the general patient population. This can lead to overestimating or underestimating the effectiveness of treatments or the accuracy of diagnostic tests.

2. Timing of Patient Recruitment

   The timing of patient recruitment is another source of selection bias. The stage of illness at which patients are recruited can affect study outcomes, especially in diagnostic studies. For example, the diagnostic value of CRP for appendicitis changes depending on when it is measured. Additionally, certain conditions may present differently depending on the time of day or week, potentially leading to an incomplete understanding of a condition's prevalence or severity if the study only includes patients from specific times.

3. Retrospective vs. Prospective Studies

   Retrospective studies, which rely on historical data, are particularly vulnerable to selection bias. These studies may selectively include data from periods with better patient outcomes, leading to skewed results. They may also suffer from incomplete data or changes in diagnostic criteria over time, making it difficult to generalize findings. Prospective studies, while more controlled, also need careful planning to avoid selection bias, especially in defining inclusion and exclusion criteria.

4. Convenience Sampling

   Convenience sampling involves selecting patients based on availability rather than a structured protocol, often due to resource limitations. This can result in a non-representative sample, such as including only daytime patients who might differ from those presenting at night. While convenience sampling can be a pragmatic choice, it often leads to underrepresentation of certain patient groups, potentially biasing study findings.

Mitigating Selection Bias

To mitigate selection bias, researchers should strive for comprehensive sampling strategies, such as random or consecutive sampling. Where complete sampling is not possible, they should transparently report potential biases and the measures taken to minimize them. For instance, using screening logs or adjusting for demographic differences can help address disparities between recruited and non-recruited patients. Sensitivity analyses can also be used to understand the impact of excluding certain patient groups.

Case Study: Thrombolysis in PEA Cardiac Arrest

A recent journal club discussion highlighted a retrospective cohort study by Shereefi et al., examining the efficacy of half-dose thrombolysis in patients with PEA cardiac arrest and confirmed pulmonary embolism (PE). The study raised concerns due to several potential biases. The arbitrary selection of a 23-month inclusion period, without a clear rationale, suggests the possibility of survival bias, as it included only patients who survived long enough to receive a confirmatory diagnosis of PE. This selective inclusion means the findings might overestimate the treatment's effectiveness, as the study only considered patients with a relatively favorable prognosis.

Moreover, the study's setting in a specialized environment and the inclusion of only confirmed PE cases limit the generalizability of the results. In practice, thrombolysis may be administered based on clinical suspicion rather than confirmed diagnosis, which involves a broader and potentially more diverse patient group. The study's focus on survivors also excludes those who may have died before a diagnosis, further skewing the data towards more favorable outcomes.

Implications of Selection Bias

Selection bias can significantly impact the interpretation of study results and, consequently, clinical decisions. It can lead to over- or underestimation of a treatment's effectiveness or the prevalence of a condition. This bias can also affect healthcare policy and practice guidelines, potentially disadvantaging underrepresented patient groups. For example, guidelines developed from biased research may fail to address the needs of older adults or those with comorbidities if these groups are underrepresented in studies.

Conclusion

Selection bias is a pervasive issue that can undermine the credibility of medical research. It arises from various sources, including the study environment, timing of recruitment, study design, and sampling methods. While complete elimination of selection bias is challenging, awareness and careful methodological design can mitigate its effects. Researchers and clinicians must critically appraise studies, considering potential biases and their implications for clinical practice. By doing so, we can make more informed decisions and improve patient care. At St. Emlyns, we continue to explore these critical appraisal topics to support evidence-based practice.

Understanding Blinding in Clinical Trials: A Comprehensive Guide

Blinding, also referred to as masking, is a crucial methodological approach used in clinical trials to eliminate bias and ensure the validity of study outcomes. This practice involves keeping study participants, clinicians, and researchers unaware of the treatment assignments. The goal is to prevent the knowledge of treatment allocation from influencing behaviors, perceptions, or evaluations, thus maintaining the integrity of the research.

Types of Blinding in Clinical Trials

Single Blinding: In this approach, only the participants are unaware of the treatment they receive. For example, in a drug trial comparing an anticoagulant to a placebo, participants do not know which they are receiving. This method helps prevent the placebo effect or other biases arising from participants' expectations. Ensuring effective single blinding requires that the placebo and active treatment appear identical in all sensory aspects, including appearance, taste, and even side effects.

Double Blinding: This method extends the concealment to both participants and the clinicians or researchers administering the treatment. It is crucial because knowledge of the treatment can influence the clinical management of the patient or the interpretation of symptoms. For example, if a doctor knows a patient is receiving a placebo, they might provide less attentive care. Double blinding helps ensure that all patients receive consistent care, and it prevents clinicians from unintentionally influencing the outcomes based on their expectations.

Triple Blinding: The most comprehensive form of blinding, triple blinding, includes blinding the data analysts as well. This method prevents bias during the interpretation of study results, as analysts are unaware of which group received the treatment. This approach is particularly important when the data analysis involves subjective judgments or when the analysis plan is not strictly predefined. Triple blinding helps ensure that data is handled objectively, leading to more reliable conclusions.

Importance of Blinding in Clinical Trials

Blinding is essential to minimize various forms of bias that can compromise the validity of clinical trials. These biases include:

1. Participant Bias: When participants know the treatment they are receiving, it can influence their reporting of symptoms and outcomes, skewing the study results.

2. Observer Bias: Clinicians and researchers may consciously or unconsciously alter their assessments based on their knowledge of the treatment allocation. This can affect how symptoms are recorded or how interventions are implemented, potentially leading to biased outcomes.

3. Analyst Bias: Data analysts may be influenced by their expectations or hypotheses if they know which treatment group participants belong to. This can affect the objectivity of the data analysis, making the results less reliable.

Practical Challenges in Blinding

Despite its importance, blinding is not always feasible or ethical in all types of studies. For example, in trials comparing physical interventions like a wrist splint versus a plaster cast, it is impossible to blind participants or clinicians due to the visible nature of the treatments. In such cases, researchers must adopt a pragmatic approach, using rigorous randomization and transparent reporting to mitigate potential biases.

A notable case highlighting the challenges of blinding is a study conducted by Dan Horner and colleagues on the treatment of calf deep vein thrombosis (DVT). The study compared the use of warfarin with no anticoagulation. Ideally, the study would have included a placebo group, but ethical and practical concerns made this impossible. Patients on warfarin require regular monitoring and dose adjustments, which could not ethically be simulated for a placebo group. As a result, the study was conducted without blinding but still provided valuable insights into the treatment's potential benefits.

Sham Interventions in Blinding

In some studies, particularly those involving surgical procedures, sham interventions are used to maintain blinding. This involves performing procedures on the control group that mimic the intervention without providing therapeutic benefits. For instance, in trials assessing surgical techniques, control group participants might undergo anesthesia and incision without actual surgery. This method is ethically sensitive but can be crucial in preventing bias from influencing the study's outcomes.

Blinding in Diagnostic Studies

Blinding is also vital in diagnostic studies, where it ensures that the assessment of diagnostic tests is not influenced by pre-existing knowledge about the patients. For instance, in evaluating a new diagnostic test like a D-dimer test for pulmonary embolism, blinding the interpreters of test results is essential. It prevents bias in the interpretation of test outcomes, ensuring that results are evaluated based on the test's performance rather than expectations or assumptions.

Conclusion

Blinding is a fundamental component of clinical trial design, crucial for minimizing bias and ensuring the validity of study findings. Whether it is single, double, or triple blinding, the technique helps maintain objectivity in clinical research, making the results more reliable and trustworthy. While blinding is not always possible, especially in trials involving visible interventions, researchers must strive to minimize bias through careful study design and transparent reporting.

As readers and critical appraisers of clinical research, it is essential to look for evidence of blinding and consider its impact on the validity of study results. Understanding the importance and challenges of blinding can help us better interpret clinical trial outcomes and make informed decisions in healthcare.

Thank you for joining us at St. Emlyn's. Stay curious, critically appraise the evidence, and continue exploring the fascinating world of clinical trials. Until next time, stay informed and engaged in advancing medical knowledge.

Understanding Randomization in Clinical Trials: A Guide for Critical Appraisal

Welcome to the St. Emlyn's blog, your go-to resource for insights into emergency medicine and critical care. Today, we're diving into a crucial aspect of clinical research: randomization. Whether you're preparing for exams like the FR-KEM or just want to deepen your understanding of clinical trials, understanding randomization is key to critical appraisal. This blog post will walk you through the essentials, common pitfalls, and best practices for ensuring robust study design.

What is Randomization?

Randomization is a foundational process in clinical trials, particularly those evaluating interventions. It refers to the random allocation of participants into different treatment groups. This process aims to eliminate selection bias and ensure that differences in outcomes can be attributed to the intervention itself rather than other factors.

Why is Randomization Important?
Randomization is crucial because it helps establish causality. Without it, studies might only reveal associations rather than true cause-and-effect relationships. For example, if we observe patients receiving different treatments in a non-randomized manner, systematic differences between the groups—such as varying standards of care—could confound the results. Randomization seeks to balance these factors, allowing for a clearer interpretation of the intervention's effectiveness.

Key Components of Randomization

1. Random Allocation: This is the process of assigning participants to treatment groups purely by chance. It can be done using random number tables, computer-generated sequences, or other methods that ensure allocation is not influenced by investigators or participants.

2. Allocation Concealment: This involves hiding the allocation sequence from those involved in enrolling participants. It's vital to prevent selection bias, where researchers might consciously or unconsciously influence the assignment of participants to specific groups.

3. Blinding: While not a part of randomization per se, blinding is closely related. It refers to keeping participants, healthcare providers, and researchers unaware of which treatment group participants are in. This prevents performance and detection biases.

Common Pitfalls in Randomization

Despite its importance, randomization can be implemented poorly, leading to biased results. Here are some common pitfalls:

• Inadequate Randomization Methods: Methods like assigning treatments based on birth dates or day of the week might seem random but can introduce systematic biases. For instance, there could be differences in care based on the day or time, making these methods unreliable.

• Failure to Conceal Allocation: In the past, brown envelope methods were used, where the treatment assignment was sealed in an envelope. However, this method is vulnerable to tampering. For instance, researchers might be tempted to "peek" at the assignment and selectively enroll participants, compromising the study's integrity.

• Small Sample Sizes: Small trials are particularly vulnerable to imbalance in baseline characteristics between groups purely by chance. This can lead to skewed results that do not accurately reflect the intervention's efficacy.

Best Practices in Randomization

To ensure robust and reliable results, certain best practices should be followed:

1. Use of Reliable Randomization Methods: In modern trials, computer-generated random numbers are the gold standard. They provide true randomness and can be tailored to the specific needs of the study.

2. Allocation Concealment Techniques: More sophisticated methods like centralized randomization, where a third party manages the allocation process, can help maintain concealment. In some studies, web-based or voice-based systems are used, which provide real-time allocation while preventing researchers from manipulating the process.

3. Stratification and Block Randomization: To address the issue of unequal distribution of participants' characteristics, stratification and block randomization are employed. Stratification involves grouping participants based on certain characteristics (e.g., disease severity) and ensuring even distribution across treatment groups. Block randomization, on the other hand, ensures that each treatment group has an equal number of participants within defined blocks, maintaining balance throughout the study.

The Role of Randomization in Analyzing Results

When analyzing the results of a randomized controlled trial (RCT), the first step is to examine the baseline characteristics of the treatment groups. This is often presented in Table 1 of a study. The purpose is to ensure that randomization has successfully created comparable groups. If significant differences exist, they could confound the results, making it harder to attribute outcomes to the intervention alone.

Another critical aspect is to consider the size of the trial. Larger studies are generally better at balancing characteristics between groups, reducing the likelihood of chance imbalances. However, even in well-randomized studies, it's possible for imbalances to occur, especially in smaller trials. Researchers must acknowledge these potential imbalances and adjust their analyses accordingly.

Practical Considerations in Emergency Medicine

In emergency medicine, the need for rapid, reliable randomization methods is particularly pressing. Web-based randomization systems offer a convenient solution, providing quick, secure, and tamper-proof allocation. Similarly, voice-based systems, where a computer assigns treatment groups via a phone call, are another practical option.

For those conducting smaller trials, there are accessible tools available, such as Sealed Envelope (sealedenvelope.com), which offers randomization services tailored to smaller studies. These tools help maintain the integrity of the randomization process, even in resource-limited settings.

Special Considerations: Trials with Diverse Populations

In clinical trials, particularly in emergency settings, researchers often encounter a wide range of patient severities. For instance, in head injury studies, patients can vary significantly in their Glasgow Coma Scale (GCS) scores. In such cases, simple randomization may inadvertently group all severe cases into one treatment arm, skewing the results.

To mitigate this, researchers use stratification, ensuring that key subgroups (e.g., GCS < 8) are evenly represented across treatment groups. This not only improves the internal validity of the study but also enhances the power of the statistical analyses, providing more reliable results.

Advanced Randomization Techniques

As trials become more complex, so do the randomization techniques. Block randomization is one such method that ensures each treatment group receives participants throughout the study, rather than in uneven waves. For example, rather than having all participants receive treatment A first, followed by treatment B, block randomization allocates treatments in smaller blocks (e.g., groups of 20), maintaining balance throughout.

This method is particularly valuable in trials with interim analyses or those that may stop early due to significant findings. It ensures that at any given point, the distribution of participants is roughly equal, allowing for fair and accurate assessment of the treatment effects.

Conclusion: The Importance of Rigorous Randomization

Randomization is the cornerstone of robust clinical trial design. It minimizes biases, balances baseline characteristics, and supports the validity of causal inferences. However, the process must be meticulously planned and executed. From choosing the right method to ensuring allocation concealment, every step is crucial in maintaining the integrity of the study.

For clinicians and researchers, understanding the nuances of randomization helps in critically appraising literature and designing their own studies. Whether you're preparing for an exam or conducting a trial, appreciating the intricacies of randomization will enhance your ability to interpret and apply clinical research findings effectively.

At St. Emlyn's, we emphasize the importance of thorough critical appraisal skills. By mastering these concepts, you'll be better equipped to discern high-quality evidence and make informed decisions in your clinical practice. Stay tuned for more insights and practical tips on navigating the world of clinical research.

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
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Year in Review: Highlights in Emergency Medicine and Critical Care

As we close out the year, St Emlyn's takes a moment to reflect on the significant events and advancements in the field of emergency medicine, critical care, and FOAMed (Free Open Access Medical Education). The past year has seen remarkable progress in research, education, and community engagement, with key studies reshaping our understanding and practices. Here's a look back at the highlights and what we can look forward to in the coming year.

Key Research and Trials

This year has been notable for the publication of several high-impact studies in emergency medicine and critical care. While some findings may have appeared negative at first glance, they have ultimately underscored the strengths of current practices. For example, trials on mechanical CPR devices, such as the Lucas device, showed no significant improvement in outcomes for out-of-hospital cardiac arrest patients. Similarly, research on starch solutions in sepsis concluded that these substances could be harmful, advocating for their discontinuation despite continued use in some clinical settings.

The ARISE and ProCESS trials were particularly influential, examining the effectiveness of early goal-directed therapy in sepsis management. Although these studies did not demonstrate a significant advantage over standard care, they highlighted the high quality of usual treatment protocols, which have improved considerably over the past decade. The ANZICS trial also reported a significant decrease in sepsis mortality, further emphasizing the advancements in patient care.

Additionally, the Targeted Temperature Management trial found no difference in outcomes between maintaining post-cardiac arrest patients at 33°C versus 36°C. This finding suggests that more aggressive temperature control may not be necessary, streamlining care protocols.

The Role of FOAMed

The FOAMed movement has revolutionized access to medical education, allowing healthcare professionals to stay updated with the latest research and discussions. Within hours of publication, new studies are analyzed and debated on various platforms, enhancing knowledge dissemination and critical appraisal.

St Emlyn's, along with other prominent FOAMed resources like Life in the Fast Lane, has played a crucial role in this educational revolution. The emergence of new platforms, such as The Bottom Line, has provided additional avenues for high-quality content. The Bottom Line, in particular, offers concise, critical appraisals of literature from a British perspective, catering to a broad audience interested in emergency medicine and critical care.

Noteworthy Blogs and Podcasts

The past year has seen an increase in the quality and quantity of blogs and podcasts in the FOAMed community. Established sites like Resus.Me, EM Lyceum, and the SGM continue to provide valuable insights, while newer entries such as Broom Docs have brought fresh perspectives. Broom Docs, led by Casey Parker, is particularly noted for its thoughtful discussions on diagnostic tests and clinical judgment.

Podcasts have also become an essential part of the FOAMed landscape. St Emlyn's own podcast has grown significantly, offering interviews with experts and discussions on a wide range of topics. Other notable podcasts include Foamcast, which presents a polished and well-structured approach to emergency medicine education, and the Rage podcast, known for its informal yet informative style.

Conferences and the Evolution of Medical Education

Conferences remain a cornerstone of professional development in emergency medicine and critical care. This year, St Emlyn's team members attended several notable conferences, including the EMS Gathering in Ireland, which featured innovative learning approaches like the "Puss Bus" for sepsis education and Pecha Kucha-style presentations. These events provided valuable opportunities for networking, knowledge exchange, and exploring new educational formats.

A significant trend in conferences is the shift towards "Medutainment," which blends medical education with entertainment. This approach, inspired by platforms like TED Talks, emphasizes engaging and visually appealing presentations over traditional lecture formats. The move towards more dynamic and interactive sessions reflects the growing demand for high-quality, engaging content in medical education.

Looking Forward to 2015

The upcoming year promises to be equally exciting for emergency medicine and critical care. The SMACC Chicago conference in June is highly anticipated, featuring a lineup of world-class speakers and sessions. Additionally, the College of Emergency Medicine's conference in Manchester is expected to be a major event, with an impressive list of speakers and topics.

At St Emlyn's, we plan to continue expanding our content offerings. Our goal is to provide comprehensive coverage of key presenting complaints in the College of Emergency Medicine curriculum through our blog and podcast. We aim to deliver high-quality educational resources that not only inform but also inspire and engage our audience.

Acknowledgements

We would like to extend our heartfelt thanks to everyone who has supported St Emlyn's and the broader FOAMed community. Special thanks go to Mike Cadogan, whose behind-the-scenes work has been instrumental in maintaining many FOAMed platforms. We also appreciate the contributions of our guest writers and the entire Life in the Fast Lane team for their invaluable support.

Conclusion

The past year has been marked by significant advancements and enriching experiences in emergency medicine and critical care. The growth of FOAMed has democratized access to knowledge, allowing healthcare professionals to stay current with the latest research and best practices. As we look forward to 2015, we are excited about the opportunities for further growth and learning. We remain committed to providing high-quality, accessible education and fostering a supportive, informed community.

We wish all our readers and listeners a happy and healthy holiday season. Whether you're spending time with family or working through the festive period, we hope you find joy and fulfillment in your work and life. Thank you for being part of our journey, and we look forward to another year of learning and growth together.