The St.Emlyn’s Podcast

Ep 154 - January 2020 Round Up

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

Ep 153 - December 2019 Round Up

Our regular round up of the best of the blog from December 2019. Published a little late, largely because of Coronavirus issues and general business.

Ep 152 - November podcast round up on St Emlyn's

The latest from the St Emlyn's blog

Ep 151 - October 2019 Round Up

St Emlyn's October 2019 Round-Up: Key Insights from Conferences and Research

October 2019 was a bustling month for the St Emlyn's team, filled with important conferences, groundbreaking research, and engaging discussions in emergency medicine. This round-up covers the highlights, from tactical trauma insights to controversial trial results, providing a comprehensive overview of the month’s most significant developments.

Tactical Trauma Conference in Sundsvall, Sweden

The month started with the Tactical Trauma Conference in Sundsvall, Sweden, where Pete Hume, a colleague from Virchester, presented on the response to the Manchester Arena bombing. This tragic event, involving many pediatric casualties, posed significant challenges in managing a high volume of injured children. Pete’s presentation highlighted the crucial lessons learned during the response, emphasizing the importance of preparedness and efficient resource management.

A standout talk at the conference was given by Geoff Yost, who discussed the 2017 Las Vegas shooting. A key takeaway from his presentation was the importance of utilizing bystanders during mass casualty incidents. Bystanders are often the first to respond, and their actions can significantly influence outcomes. This was exemplified by the recent London Bridge attack, where members of the public intervened using improvised weapons like a narwhal tusk.

Pete also provided insights into leadership in crisis situations, a topic covered by Kate Pryor at the conference. Overall, the Tactical Trauma Conference underscored the need for collaboration with bystanders and the importance of effective leadership during emergencies.

R.CEM Annual Scientific Conference in Gateshead

The R.CEM Annual Scientific Conference, held in Gateshead at the end of October, brought together emergency clinicians, nurses, paramedics, and researchers to discuss the latest developments in emergency medicine. Chris Gray, a member of the St Emlyn's team, attended and shared his experiences through a series of blog posts.

One of the most anticipated studies discussed at the conference was the NOPE PAX study on the use of tranexamic acid for treating nosebleeds. Although the results are not yet publicly available, the study is expected to provide valuable insights into this increasingly popular treatment. Another key study was the CAP-IT study, which focuses on the use of antibiotics in pediatric pneumonia—a topic of ongoing debate in the context of antibiotic stewardship.

The conference also featured discussions on the CRASH-3 trial, particularly concerning the use of tranexamic acid in traumatic brain injury. Ian Roberts delivered a compelling presentation on the mechanisms of tranexamic acid and the significant differences in its use across various regions, including the UK, the US, and Australasia.

The TERN Network and the TIRED Study

A major highlight of the R.CEM conference was the presentation of the TIRED study, the first major project from the Trainees Emergency Research Network (TERN). Led by Dan Horner, the study surveyed the levels of fatigue among emergency physicians across the UK, using the Need for Recovery Score to assess recovery time after shifts.

The study revealed concerning results, with emergency clinicians scoring an average of 73 on the Need for Recovery Score, significantly higher than the previous highest score of 55 recorded for Iranian miners. This suggests that emergency clinicians are under immense pressure, leading to high levels of fatigue.

Interestingly, older clinicians had lower scores, indicating either greater resilience or better workload management. However, the study raises the controversial question of whether the job’s demands are causing some clinicians to leave the profession early.

The TERN network is continuing to explore critical questions in emergency medicine, with upcoming studies on subarachnoid hemorrhage and the necessity of lumbar punctures.

European Resuscitation Council Meeting in Slovenia

The European Resuscitation Council meeting in Slovenia was another key event in October. The chain of survival—early recognition, CPR, defibrillation, and post-resuscitation care—was a major focus of the conference. While much attention is often given to post-resuscitation care, the most significant impact on survival comes from the early stages of the chain.

The GoodSAM app, which allows trained responders to be notified of nearby emergencies, plays a crucial role in this early response. The app has already made a significant difference in several cases, including cardiac arrests.

Another important discussion at the conference was the use of hypothermia in post-cardiac arrest care. Following the TTM1 trial, which suggested that hypothermia might not be as beneficial as once thought, some clinicians have stopped temperature management altogether. However, evidence presented at the ERC meeting indicates that this may have led to an increase in post-arrest mortality. The ongoing TTM2 trial aims to provide more clarity on the role of hypothermia in post-cardiac arrest care.

Thromboprophylaxis in Lower Limb Immobilization

Dan Horner’s study on thromboprophylaxis in lower limb immobilization is another significant piece of research published this month. The study, a systematic review, highlighted that the incidence of significant deep vein thrombosis (DVT) in patients with lower limb immobilization is around 2%, and anticoagulation almost certainly reduces this risk.

However, the study also pointed out that there is no clear consensus on which risk stratification tool is best for identifying patients at risk of DVT. The GemNet guidelines from R.CEM are a solid option, but more research is needed in this area. The study also discussed the choice of anticoagulant, noting that while low-molecular-weight heparin is the most commonly used, the use of DOACs, such as rivaroxaban, is on the rise.

As an emergency physician, the balance between preventing life-threatening complications like pulmonary embolism and avoiding significant bleeding events remains a critical consideration in patient care.

Top 10 Papers from 2018-2019

The R.CEM Annual Scientific Conference also featured a presentation on the top 10 papers from the past year, covering a wide range of topics in emergency medicine.

One key study explored whether early or delayed cardioversion should be performed in recent-onset atrial fibrillation, with the conclusion leaning towards not immediately intervening. Another study examined whether ventilation should continue during RSI (rapid sequence induction), with evidence suggesting that it should.

The debate over cricoid pressure during RSI continues, with recent evidence indicating that it may not be necessary and could even be harmful in some cases. Magnesium in atrial fibrillation was also discussed, with the evidence supporting its use, particularly when combined with other treatments.

The presentation also covered the use of vasopressors in hemorrhagic shock, with early evidence suggesting they might be beneficial, though more research is needed. Finally, the discussion touched on diagnosing pulmonary embolism in pregnancy using the YEARS score, a promising but still developing area of research.

The CRASH-3 Trial: A Controversial Conclusion

The CRASH-3 trial, focusing on the use of tranexamic acid in traumatic brain injury, has generated significant debate in the emergency medicine community. While the trial’s findings have already started to influence practice in the UK, the way the results were interpreted and publicized has been controversial.

The debate centres around two main camps: one that argues the trial didn’t conclusively prove that tranexamic acid reduces mortality in traumatic brain injury and another that believes the evidence strongly suggests a benefit in certain subgroups. While not the final word on the subject, the CRASH-3 trial provides enough evidence to justify the use of tranexamic acid in specific scenarios.

Looking Ahead

As October ends and November begins, there’s much to look forward to. The Asian Conference of Emergency Medicine in India promises to be an exciting event, and the Resuscitology Conference in December is already sold out, with plans to run it again in 2020.

Emergency medicine is more intense than ever, with record numbers of patients and some of the toughest days experienced in the field. Despite these challenges, the St Emlyn's team continues to provide exceptional care and remain at the forefront of emergency medicine research and practice.

Thank you for following along with this month’s round-up. Stay tuned for more updates from St Emlyn's as we continue to explore, learn, and share the latest in emergency medicine.

 

 

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Ep 150 - REBOA with Zaf Qasim

Simon and Zaf talk about the practicalities of REBOA and discuss whether it's ready for prime time in the UK.

Introduction

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a minimally invasive technique designed to control hemorrhage in patients with life-threatening bleeding and offers a bridge to definitive surgical intervention. Here at St Emlyn’s, we are committed to exploring innovative solutions that enhance patient outcomes in emergency medicine. In this post, we delve into the essentials of REBOA, its clinical application, benefits, and challenges.

Understanding REBOA

REBOA involves the insertion of a balloon catheter into the aorta via the femoral artery. By inflating the balloon, we can occlude the aorta, thus controlling bleeding below the point of occlusion. This procedure is particularly useful in cases of non-compressible torso haemorrhage, where traditional methods of haemorrhage control are inadequate.

Indications and Contraindications

Indications:

1. Hemorrhagic shock from pelvic fractures or abdominal bleeding.
2. Trauma patients with signs of severe hemorrhage unresponsive to fluid resuscitation.
3. As a temporary measure until surgical control of bleeding is achieved.

Contraindications:

1. Patients with known aortic pathology (e.g., aortic dissection).
2. Significant injury above the diaphragm.
3. Prolonged transport times where REBOA may not be beneficial.

The Procedure

Preparation

Before performing REBOA, it is crucial to ensure that the patient is appropriately resuscitated and stabilized as much as possible. This includes securing the airway, ensuring adequate ventilation, and achieving initial hemodynamic stabilization.

Insertion and Inflation

1. Vascular Access: Gain access to the common femoral artery using ultrasound guidance to minimize complications.
2. Catheter Insertion: Insert the REBOA catheter through a sheath into the femoral artery. Advance the catheter under fluoroscopic or ultrasound guidance to the desired level in the aorta (Zone I: above the celiac artery for abdominal hemorrhage, Zone III: above the bifurcation of the iliac arteries for pelvic hemorrhage).
3. Balloon Inflation: Inflate the balloon to occlude the aorta. This temporarily controls bleeding and allows time for definitive surgical repair.

Monitoring and Maintenance

Continuous monitoring of vital signs and catheter position is essential. The occlusion time should be minimized to reduce ischemic complications. Ideally, REBOA should serve as a bridge to definitive surgical intervention within 30-60 minutes.

Benefits and Challenges

Benefits

1. Rapid Hemorrhage Control: REBOA can quickly control bleeding, buying crucial time for surgical intervention.
2. Less Invasive: Compared to traditional open thoracotomy with aortic cross-clamping, REBOA is less invasive, reducing associated morbidity.
3. Improved Survival Rates: Emerging evidence suggests that REBOA can improve survival rates in appropriately selected trauma patients.

Challenges

1. Technical Expertise: REBOA requires specific training and expertise. Improper technique can lead to significant complications.
2. Ischemic Complications: Prolonged aortic occlusion can lead to ischemia of distal organs and tissues, necessitating careful monitoring and timely deflation.
3. Resource Intensive: REBOA demands resources such as fluoroscopy, ultrasound, and trained personnel, which may not be available in all settings.

Conclusion

REBOA represents a promising advancement in trauma care, offering a vital tool in the management of life-threatening haemorrhage, but it's utility in the Emergency Department is uncertain.

Further reading

EMCrit guest post - the good, the bad, the ugly of the (original) Joint Statement https://emcrit.org/emcrit/good-bad-ugly-of-joint-statement-reboa/

 

Updated 2019 Joint Statement from the ACS-COT, ACEP, NAEMSP, and NAEMT: https://tsaco.bmj.com/content/4/1/e000376.info

 

London Air Ambulance Prehospital REBOA Case series: https://linkinghub.elsevier.com/retrieve/pii/S0300-9572(18)31110-9

Ep 149 - September 2019 Round Up

A Month in Review: Key Takeaways from St Emlyn's September 2019 Content

Welcome to a detailed overview of the latest content from St Emlyn's, focusing on the valuable insights and educational resources we shared throughout September 2019. This month’s offerings span a wide range of topics, from the evolving concept of the "resuscitationist" to the increasing challenges posed by decompensated liver disease, and the ongoing development of emergency medicine education. Here’s a look at the most important takeaways.

The Resuscitationist: More Than Just a Title

The term "resuscitationist" has become a buzzword within the emergency medicine (EM) and critical care communities, especially following its emergence from the SMACC (Social Media and Critical Care) conferences. Dan Horner delved into this concept in a recent presentation, sparking a broader discussion about what it truly means to identify as a resuscitationist.

At its core, being a resuscitationist isn’t just about having an interest in the resuscitation room. It requires a blend of sharp clinical skills, deep knowledge of resuscitation science, and the ability to apply evidence-based practices effectively. But beyond technical expertise, leadership and teamwork are crucial. A resuscitationist must excel in managing high-stakes, chaotic situations where decisions are made with limited information and under intense time pressure.

Moreover, Dan highlights the importance of humility and collaboration. The best resuscitationists are those who recognize their own limitations and are skilled at drawing on the strengths of others, whether from different specialties or professions. This collaborative approach not only enhances patient care but also builds stronger, more effective resuscitation teams.

Decompensated Liver Disease: A Growing Concern in the ED

Liver disease is on the rise, particularly due to lifestyle factors like alcohol consumption and obesity. Gareth Roberts tackled this pressing issue in his blog post on decompensated liver disease, which is becoming increasingly common in emergency departments (EDs) across the UK and beyond.

Gareth outlines a comprehensive care bundle designed to manage patients with decompensated liver disease effectively. This bundle includes seven key points:

1. Thorough Investigation: Quick and accurate investigations are essential, particularly for detecting complications like spontaneous bacterial peritonitis (SBP), which can be life-threatening.

2. Infection Management: Aggressive treatment of infections is critical, with a focus on using appropriate antibiotics and monitoring for SBP.

3. Acute Kidney Injury (AKI) and Hyponatremia: These complications are common in liver disease patients and must be managed carefully. Gareth discusses the potential benefits of human albumin in these cases.

4. GI Bleeding: Gastrointestinal bleeding, especially from varices, poses a significant risk. Gareth directs readers to additional resources on St Emlyn’s, including a presentation by Chris Gray on managing GI bleeding.

5. Hepatic Encephalopathy: This condition can severely alter a patient’s mental status and requires careful management. With the increasing prevalence of liver disease, understanding and managing hepatic encephalopathy is more important than ever.

Gareth’s post is a must-read for anyone dealing with liver disease in the ED, providing both practical advice and links to further resources.

Expanding Education: The MSc in Emergency Medicine

Education is a cornerstone of St Emlyn’s, and we’re excited to announce the expansion of the MSc in Emergency Medicine at Manchester Metropolitan University. This program has been running successfully for several years and is now broadening its scope to include paramedics, making it a truly multi-professional and multi-disciplinary course.

The MSc program offers a variety of modules tailored to the specific needs of different healthcare professionals. Whether you’re looking to deepen your clinical knowledge, enhance your leadership skills, or explore new areas of emergency medicine, this program has something to offer. For more details, visit our website or reach out directly.

Supporting St Emlyn’s: Keep Our Content Free and Accessible

St Emlyn’s remains committed to providing free and open-access content to the global emergency medicine community. However, maintaining and expanding our offerings requires resources. If you find value in what we provide, please consider supporting us financially. Even a small contribution can help us continue to deliver high-quality content to healthcare professionals worldwide.

Introducing Coda: The Next Evolution After SMACC

Coda is the latest evolution in the SMACC legacy, aiming to broaden the scope of its predecessor by incorporating a wider range of specialties, including oncology, public health, and surgery. As a member of the Coda executive team, I can attest to the ambitious goals of this new conference series.

Coda retains the clinical excellence that SMACC was known for, but with an added emphasis on advocacy. Each year, Coda will tackle a significant global health issue, with the inaugural theme focusing on climate change and its impact on medical practice.

It’s important to note that while climate change is a key focus, it won’t dominate the entire conference. Only about 25% of the program will be dedicated to this theme, with the remaining 75% featuring the high-quality clinical content you’ve come to expect from SMACC. The first Coda conference is set to take place in Melbourne in 2020, and we encourage you to participate, whether in person or remotely.

The Zero Point Survey: A Game-Changer in Resuscitation

The Zero Point Survey, a concept championed by Cliff Reid, is gaining widespread recognition for its transformative impact on resuscitation practices. The idea shifts the focus of the primary survey in resuscitation from when you first encounter the patient to what you do before you even meet them.

This approach emphasizes the importance of preparation—both mental and environmental. By optimizing everything you can control before the patient arrives, you set the stage for delivering high-quality care when it matters most.

Feedback from the EM community has been overwhelmingly positive, with many clinicians reporting that the Zero Point Survey has changed how they manage the resuscitation room. It’s not just a theoretical concept; it’s a practical tool that’s making a real difference in patient outcomes.

If you’re not yet familiar with the Zero Point Survey, I strongly encourage you to explore the resources available on the St Emlyn’s website, including an excellent video by Cliff Reid that outlines the key elements of this approach.

Looking Ahead: What’s Next for St Emlyn’s?

As we wrap up our review of September’s content, it’s clear that the St Emlyn’s team has been hard at work bringing you the latest in emergency medicine education and clinical practice. But there’s much more to come.

In the coming months, we’ll be covering exciting topics at upcoming conferences, including the ArchiEM conference in Gateshead and the Slovenia ERC conference. These events promise to bring fresh insights and new perspectives that we’ll be sharing with you through our blog posts and podcasts.

In the meantime, keep doing the incredible work you do in emergency medicine. It’s a challenging field, but it’s also incredibly rewarding, and you’re making a difference every day. Thank you for being part of the St Emlyn’s community, and I look forward to continuing this journey with you.

Stay tuned for more great content, and as always, keep pushing the boundaries of what’s possible in emergency care.

Ep 148 - CRASH-3

The CRASH-3 Trial: Revolutionizing Head Injury Management with Tranexamic Acid

The CRASH-3 trial, a landmark study in the field of emergency medicine, has brought significant attention to the potential role of tranexamic acid (TXA) in managing traumatic brain injury (TBI). As one of the largest randomized controlled trials ever conducted on head injury patients, its findings could reshape clinical practices globally, particularly in the pre-hospital and emergency department settings.

Overview of the CRASH-3 Trial

The CRASH-3 trial was designed to assess the efficacy of TXA in reducing mortality among patients with traumatic brain injury. TXA is an antifibrinolytic agent commonly used to prevent excessive bleeding in various medical scenarios, such as trauma, surgery, and postpartum hemorrhage. The question posed by CRASH-3 was whether TXA could also reduce deaths in patients who had suffered a TBI, a question that had remained unanswered despite the success of the CRASH-2 trial in managing extracranial bleeding.

Patient Population and Inclusion Criteria

The trial focused on adults aged 16 years and older who had sustained a traumatic brain injury. To be included, patients needed to have either a Glasgow Coma Scale (GCS) score of 12 or lower or a positive CT scan indicating intracranial bleeding. Notably, patients with significant extracranial bleeding were excluded from the trial to specifically measure the effect of TXA on TBI outcomes.

A critical aspect of the trial was the timing of TXA administration. Initially, the protocol allowed TXA to be administered within eight hours of injury. However, as data from other studies like the WOMAN trial and CRASH-2 became available, suggesting that the benefits of TXA diminish after three hours, the protocol was adjusted. This change meant that the majority of patients received TXA within three hours of injury, a key factor in the study's final analysis.

Key Findings of the CRASH-3 Trial

The CRASH-3 trial enrolled 12,737 patients across 29 countries, making it one of the most extensive studies of its kind. The primary outcome measured was all-cause mortality at 28 days post-injury. The results showed that overall mortality was slightly lower in the TXA group (18.5%) compared to the placebo group (19.8%), although this difference was not statistically significant.

However, a pre-specified subgroup analysis provided more compelling evidence. When patients with a GCS of 3 and bilateral unreactive pupils (indicating very severe brain injury) were excluded, TXA demonstrated a more significant benefit. In this subgroup, the mortality rate was 12.5% in the TXA group versus 14% in the placebo group, a statistically significant reduction with a relative risk of 0.89. This finding suggests that TXA is particularly beneficial for patients with moderate head injuries (GCS 9-15) who are more likely to survive if bleeding is controlled.

Number Needed to Treat (NNT)

One of the critical metrics for evaluating the effectiveness of a treatment is the number needed to treat (NNT). In the CRASH-3 trial, the NNT was 67, meaning that 67 patients would need to be treated with TXA to save one additional life at 28 days post-injury. For comparison, the NNT for aspirin in acute myocardial infarction is about 42, which is widely regarded as highly effective. An NNT of 67 is therefore quite favorable in the context of emergency medicine, particularly for a condition as serious as traumatic brain injury.

Timing of Administration

The CRASH-3 trial strongly reinforced the importance of administering TXA as early as possible after a head injury. The data indicated a 10% reduction in TXA’s effectiveness for every 20-minute delay in patients with mild to moderate head injury. This underscores the need for TXA to be administered in the pre-hospital setting, ideally by paramedics at the scene or en route to the hospital. Delaying treatment until after arrival at the emergency department or after conducting a CT scan may significantly reduce the drug's benefits.

Implications for Clinical Practice

The results of the CRASH-3 trial suggest that TXA should be considered for all patients with moderate traumatic brain injury, particularly those with a GCS of 9 to 15 and confirmed intracranial bleeding. For patients with severe head injuries (GCS of 8 or less, or with bilateral unreactive pupils), the benefits of TXA are less clear, likely due to the severity of the primary brain injury.

Given the trial’s findings, it is recommended that TXA be integrated into clinical protocols for the management of head injuries. This is especially relevant in pre-hospital care, where early intervention is possible. TXA should be administered as soon as possible after the injury occurs, particularly in cases where a significant delay in getting to the hospital is expected.

Cost-Effectiveness and Accessibility

Another important aspect of TXA is its cost-effectiveness. In the UK, a 1-gram dose of TXA costs approximately £1, making it an affordable treatment option for healthcare systems worldwide. This low cost makes TXA a viable option not only in high-income countries but also in low- and middle-income countries where healthcare resources are often limited. Given its affordability and the potential to save lives, TXA is an attractive option for widespread use in managing traumatic brain injury globally.

Considerations for Special Populations

Although the CRASH-3 trial focused on adults, there is a strong rationale for extending its findings to pediatric patients. The physiology of traumatic brain injury in children is similar to that in adults, and there is no evidence to suggest that TXA would act differently in a younger population. As such, it would be reasonable to use TXA in children with TBI, following the same dosing guidelines adjusted for body weight.

Future Directions: Intramuscular TXA and Beyond

While CRASH-3 has provided valuable insights, research into TXA’s potential uses continues. One area of interest is the development of intramuscular (IM) TXA, which could be particularly useful in pre-hospital settings where intravenous (IV) access is challenging. The possibility of an auto-injector for TXA is also being explored, which could simplify administration and further broaden its use, especially in resource-limited settings.

Conclusion: Implementing CRASH-3 Findings in Practice

The CRASH-3 trial marks a significant advancement in our approach to treating traumatic brain injury. The evidence strongly supports the use of TXA, particularly in patients with moderate head injuries who receive the drug within three hours of injury. TXA is safe, cost-effective, and easy to administer, making it a valuable tool in both pre-hospital and hospital settings.

The implementation of CRASH-3’s findings into clinical practice could save thousands of lives annually, particularly in settings where early intervention is possible. As the emergency medicine community, we must act swiftly to incorporate these findings into our protocols and training, ensuring that TXA is used effectively to improve outcomes for patients with traumatic brain injury worldwide.

Ep 147 - August 2019 Round Up

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.

Ep 146 - European Resus Council meeting Slovenia 2019

A vox pop round up of the best of the ERC19 conference in Slovenia.

Ep 145 - The UK Resuscitationist with Dan Horner at #stemlynsLIVE

Our latest podcast from the #stemlynsLIVE conference last year. Dan Horner talks on the concept and potential role of the UK Resuscitationist.

Ep 144 - July 2019 Round Up

 

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.

Ep 143 - The Future of Diagnostics with Rick Body

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

Ep 142 - Psychological performance in the Resus Room with Ashley Liebig

This talk focuses on how we can optimise our psychological performance in critical care situations, the type of situations that Simon describes as Time Critical, Information light. The Audio is available below, or watch the full presentation above.

Don't forget to watch the video on the St Emlyn's site http://www.stemlynsblog.org

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Ep 141 - June 2019 Round Up

 

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.

Ep 140 - GI emergencies with Chris Gray at #stemlynsLIVE

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

 

Ep 139 - May 2019 Round Up

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.

Ep 138 - Traumatic Cardiac Arrest with Prof Jason Smith RN

The Evolution of Traumatic Cardiac Arrest Management: Military Insights and Civilian Applications

Traumatic cardiac arrest (TCA) is a critical and often fatal condition encountered in both military and civilian emergency medicine. Historically, the prognosis for patients with TCA has been poor, leading many to believe that resuscitation efforts are largely futile. However, recent developments, particularly those arising from military experience, are challenging this perspective. In this post, we explore insights shared by Dr. Jason Smith, a consultant in emergency medicine and a seasoned military doctor, about the evolving understanding of TCA, including the role of chest compressions and the application of military practices in civilian settings.

Traumatic Cardiac Arrest: Insights from Military Experience

TCA is relatively rare in civilian settings, with major trauma centres like Plymouth seeing a case every one to two months. However, in military environments, where high-velocity injuries are more common, TCA occurs more frequently. Dr. Jason Smith’s experience in Afghanistan revealed that traumatic cardiac arrests happened as often as three to four times a week. This stark contrast has driven the development of specific management protocols in military settings, where hemorrhagic shock is the leading cause of TCA.

In these high-intensity environments, the focus is on immediate and aggressive interventions. These protocols, developed on the battlefield, have significantly improved outcomes and are now being adapted for civilian trauma centres, where they continue to challenge the longstanding belief that TCA is nearly always fatal.

From the Battlefield to the Emergency Room: Evolving TCA Management

Over the past decade, the management of TCA has undergone significant evolution, largely influenced by military practices. Dr. Smith’s team in Afghanistan developed a "bundle of care" designed to rapidly and effectively address the key factors leading to TCA. This bundle includes:

1. External Hemorrhage Control involves ensuring that tourniquets are properly applied and functioning, alongside other measures to control external bleeding.
2. Oxygenation and Ventilation: Rapid intubation and ventilation to maintain oxygen delivery to vital organs.
3. Bilateral Thoracostomies: Decompressing the chest on both sides to manage potential tension pneumothorax.
4. Rapid Volume Replacement: Administer warm blood and blood products intravenously or intraosseously to quickly replace lost volume.
5. Pelvic Binding: Applying a pelvic binder in cases of blunt trauma to reduce pelvic volume and control bleeding.
6. Consideration of Thoracotomy: In specific cases, such as penetrating trauma to the chest, thoracotomy is considered as a life-saving intervention.

This structured approach, honed in military contexts, has led to outcomes that are significantly better than those reported in civilian literature at the time. These practices are now being adapted for civilian use, where they are helping to improve survival rates for TCA patients.

Challenging Old Assumptions: New Data on TCA Survival

One of the most significant shifts in the perception of TCA has come from recent data showing that survival rates are not as dismal as previously thought. In military populations from Iraq and Afghanistan, survival rates from TCA have been reported at around 10.6%. Even more compelling is data from the UK’s TARN database, which indicates a 7.5% survival rate for civilian TCA cases, including those caused by blunt trauma.

These figures are comparable to survival rates for non-traumatic cardiac arrest, leading to a reassessment of TCA management. The traditional view that resuscitation in TCA is futile is increasingly being challenged by evidence that with the right interventions, survival is possible.

The Controversy Around Chest Compressions in TCA

One of the most hotly debated topics in TCA management is the role of closed chest compressions. In standard Advanced Life Support (ALS) protocols, chest compressions are a fundamental part of resuscitation. However, in the context of TCA, particularly hemorrhagic TCA, their effectiveness has been called into question.

Dr. Smith’s research has played a pivotal role in this debate. He observed that during resuscitation in Afghanistan, the use of a Belmont rapid infuser often resulted in alarms indicating that chest compressions were creating too much pressure inside the thorax, preventing effective blood transfusion. This led to the hypothesis that chest compressions might be not only ineffective but potentially harmful in hemorrhagic TCA.

To explore this hypothesis, Dr. Smith and his colleagues at DSTL Porton Down developed an animal model using swine to simulate TCA. The study aimed to replicate the conditions seen in hemorrhagic TCA by bleeding the animals to a mean arterial pressure (MAP) of 20 mmHg. The animals were then divided into groups to compare the outcomes of different resuscitation strategies, including chest compressions alone, blood transfusion alone, and combinations of the two.

Key Findings: Prioritizing Blood Over Compressions

The study’s results were revealing. Animals that received blood transfusions without chest compressions had significantly better outcomes than those that received chest compressions alone or in combination with blood transfusion. Specifically, all animals that received only chest compressions were dead by the end of the study, while those that received blood alone showed signs of return of spontaneous circulation (ROSC).

Moreover, when chest compressions were combined with blood transfusion, the results were mixed. While some animals achieved partial ROSC, the overall survival was lower than in the group that received blood alone. This led to the conclusion that in hemorrhagic TCA, chest compressions might be not only unnecessary but potentially detrimental.

These findings, while based on animal models, have significant implications for clinical practice. They suggest that in cases where haemorrhage is the primary cause of TCA, the focus should be on rapid volume replacement with blood and blood products rather than on chest compressions.

Translating Research into Practice

While Dr. Smith’s study provides compelling evidence, applying these findings to human practice requires careful consideration. The study’s limitations, including its reliance on animal models and the specific conditions of hemorrhagic TCA, mean that more research is needed to fully understand how these findings apply to diverse patient populations.

However, the study does provide a strong foundation for re-evaluating current protocols. In situations where haemorrhage is identified as the primary cause of TCA, emergency teams might consider prioritizing volume replacement over chest compressions, especially in environments where rapid blood transfusion is possible.

The challenge, as Dr. Smith noted, lies in training and protocol development. Chest compressions are deeply ingrained in resuscitation practice, and changing this mindset requires robust training and clear guidelines. Emergency departments and trauma centres need to prepare their teams for scenarios where the traditional approach might not be the best one, ensuring that all members are aligned in their approach to TCA management.

Conclusion: A New Paradigm for Traumatic Cardiac Arrest

The management of traumatic cardiac arrest is evolving, driven by insights from military medicine and supported by emerging data from civilian practice. While challenges remain, particularly in shifting entrenched practices around chest compressions, the future of TCA management looks promising. Survival rates once thought to be negligible, are improving as we better understand the mechanisms at play and refine our interventions accordingly.

For emergency medicine practitioners, staying informed about these developments is crucial. As more data becomes available and as we continue to learn from both military and civilian experiences, the protocols for TCA will undoubtedly continue to evolve. The days of viewing traumatic cardiac arrest as a futile scenario are fading. With the right approach, training, and tools, we can offer these patients a fighting chance at survival.

In summary, putting science into the argument has been a game-changer, and continuing to blend evidence with practice will be key to improving outcomes in this challenging area of emergency medicine.

Ep 137 - Beyond ATLS with Alan Grayson at #stemlynsLIVE

Alan Grayson takes us through his thoughts on ATLS. Is it really as terrible the #FOAMed world makes out?

Ep 136 - Wellbeing for the broken with Liz Crowe

Navigating a Mental Health Crisis in Healthcare: A Guide to Recovery

Healthcare professionals, particularly those working in critical care and emergency medicine, often face intense situations that test their emotional and mental resilience. While most of the time, we manage to cope with the challenges, there are rare moments that catch us completely off guard, leaving us feeling utterly broken. This guide explores what to do when work breaks you—a situation that is seldom discussed but is profoundly important.

Understanding the Crisis Point

It's crucial to distinguish between the routine stressors of healthcare work and a true mental health crisis. The latter is not just a rough day or a series of challenging weeks. Instead, it's a once-in-a-career event that completely shakes your confidence and leaves you questioning your ability to continue in your role. These moments can be triggered by traumatic patient cases, critical errors, or cumulative stress that finally overwhelms you.

When such a crisis occurs, it’s important to recognize that what you're experiencing goes beyond normal stress—it’s a mental health crisis. Symptoms may include tremors, uncontrollable crying, sleeplessness, and a sense of detachment. These are signs that your mental health is under severe strain, and they should be taken seriously.

Preparing for a Crisis Before It Happens

One of the most valuable steps you can take is to prepare for the possibility of a mental health crisis before it happens. Just as we plan for emergencies in our professional roles, we should also have a plan in place for our mental well-being.

1. Build a Support Network: Identify a few trusted individuals—whether colleagues, friends, or family—who can be your go-to support in times of crisis. Share with them the kinds of situations that might overwhelm you and how they can help if the time comes.

2. Establish a Routine: Develop a daily routine that includes exercise, healthy eating, and regular sleep. Routine can serve as a stabilizing force during a crisis, providing a sense of normalcy when everything else feels chaotic.

3. Seek Professional Help: It’s wise to establish a relationship with a therapist or counsellor before a crisis hits so you have someone to turn to when you need it. If therapy isn’t an option, know how to access support through your GP or other services.

4. Practice Self-Care: Identify activities that help you relax and de-stress. Whether it’s meditation, reading, or spending time with loved ones, incorporate these into your routine. These activities can become particularly crucial during a crisis.

What to Do During a Crisis

When you find yourself in the midst of a mental health crisis, your judgment may be impaired, making it difficult to make decisions or know what to do next. Here’s how to navigate those critical moments:

1. Reach Out for Support: Even though your instinct may be to withdraw, it’s essential to reach out to someone in your support network. Connection is key to navigating a crisis. Tell them what’s happened and how you’re feeling, even if it feels incredibly difficult to do so.

2. Stick to Your Routine: Maintain your daily routine as much as possible, even if it feels challenging. Simple actions like getting up at the same time, eating regular meals, and exercising can help you regain a sense of control.

3. Avoid Self-Medication: The temptation to numb your feelings with alcohol, drugs, or other substances can be strong during a crisis. However, these can exacerbate the situation. If you feel the need for medication, consult with a healthcare professional instead of self-medicating.

4. Seek Professional Help: If you’re struggling to cope, don’t hesitate to seek professional assistance. Talking to a professional, whether through your GP, a therapist, or a crisis hotline, can provide the validation and support you need.

The Path to Recovery

Once the immediate crisis has passed, the journey to recovery begins. This process is often slow and requires patience, self-compassion, and continued support.

1. Allow Yourself Time: Recovery from a work-related mental health crisis takes time, often longer than expected. Be patient with yourself and understand that healing is a gradual process that may take months or even years.

2. Maintain Your Routine: Continue the routine that helped you during the crisis. Regular exercise, healthy eating, and sufficient sleep are the foundations of good mental health and will support your recovery.

3. Reconnect with Your Purpose: Reflect on why you chose your profession and what you love about your job. Reconnecting with these motivations can help you find meaning and purpose again, even after a traumatic experience.

4. Set Small Goals: During your recovery, set small, achievable goals rather than overwhelming yourself with big plans. Celebrate small victories, whether it’s getting through a day at work, completing a project, or simply feeling a bit better.

5. Practice Self-Compassion: Treat yourself with the same compassion you would offer a friend or colleague going through a similar situation. Acknowledge your progress, and don’t be too hard on yourself if recovery takes longer than expected.

Dealing with Shame and Guilt

One of the most challenging aspects of recovery is dealing with feelings of shame and guilt, which can be powerful and difficult to overcome.

1. Acknowledge Your Feelings: It’s normal to feel shame and guilt after a traumatic event, but also understand that these feelings are often irrational and not based on reality.

2. Challenge Negative Thoughts: When feelings of shame or guilt arise, challenge them by asking yourself if they are truly justified. Often, these feelings are rooted in distorted thinking patterns that can be corrected.

3. Talk About It: Sharing your feelings with someone you trust can help alleviate the burden of shame and guilt. Expressing these emotions can reduce their power over you and facilitate healing.

4. Focus on the Positive: Remind yourself of all the good you’ve done in your career. Think about the lives you’ve touched and the positive impact you’ve had. Your career is more than just one event; it’s a series of contributions that define your professional journey.

Moving Forward

At St. Emlyn’s, we believe that your narrative as a healthcare professional is not defined by a single event. You are more than the challenges you’ve faced, and you have the strength to overcome even the most difficult moments. Remember that you are part of a community that understands what you’re going through and is here to support you.

1. Stay Connected: Don’t let the crisis isolate you. Stay connected with your colleagues, friends, and family, who can provide support, perspective, and encouragement as you move forward.

2. Keep Learning: Use your experience as an opportunity for growth. Reflect on what you can learn from the crisis and how it can make you a better healthcare professional.

3. Be Compassionate: Always remember to be compassionate towards yourself. Healing from a work-related mental health crisis is not easy, but with time, support, and self-care, you can emerge stronger and more resilient.

Conclusion

If you’ve experienced or are currently going through a mental health crisis due to work, know that you are not alone. The feelings of being broken, the shame, the guilt, and the fear are all part of the process—but they do not define you. By preparing in advance, seeking support, and practising self-compassion, you can navigate even the darkest moments.

At St. Emlyn’s, we’re here to remind you that your worth is not measured by your worst days. Your career is a journey, and while it may have its challenges, it is also filled with moments of profound impact, healing, and growth. Take the time to care for yourself, to heal, and to reconnect with your purpose. You are important, and your work is valued.

Ep 135 - April 2019 Round Up

St. Emlyn's April 2019 Podcast Highlights

Hello and welcome to the St. Emlyn's blog. I'm Simon Carley, and today I'll be sharing the exciting developments from April 2019 on our St. Emlyn's blog. This month has been packed with insightful posts and groundbreaking research, so let's dive in.

Andromeda Shock Trial: A New Perspective

We begin with a thought-provoking journal club post by Dan Horner, an intensivist and emergency physician, who explores the Andromeda Shock trial. This study, conducted in Argentina, compared two resuscitation strategies for patients with septic shock: targeting lactate levels versus peripheral perfusion as measured by capillary refill time.

The Andromeda Shock trial is fascinating because it challenges our reliance on measurable indicators like lactate levels. Many experts argue that lactate doesn't provide the information we think it does about sepsis. Rich Carden's excellent blog on lactate delves into this topic, explaining why the common assumption that lactate indicates anaerobic metabolism is incorrect. Insights from leading intensivists like John Mayberg and Simon Finfer prompt a reevaluation of how we interpret lactate levels.

In the trial, patients managed using peripheral perfusion monitoring showed better outcomes than those managed by lactate levels. Although the trial is underpowered to show definitive differences, the findings suggest that both methods are likely similar in effectiveness. This study highlights the need to reconsider our approach to monitoring septic shock patients and suggests that capillary refill time could be a valuable, low-cost alternative to lactate measurement.

Enhancing Learning with Minimal Effort

Next, we turn to an intriguing blog by Nick Smith, who shares a lazy yet effective way to enhance learning. Inspired by Matthew Walker's book "Why We Sleep," Nick discusses the critical role of rest in learning and retention. The key takeaway is simple: if you're not well-rested before and after learning, you won't retain information effectively.

Nick emphasizes understanding individual learning rhythms. Some people, like early risers, learn best in the morning, while night owls perform better later in the day. This insight is crucial for medical educators and learners alike. For instance, teenagers naturally have later sleep cycles, making early morning learning sessions less effective.

Walker’s book provides compelling evidence on how sleep affects cognitive function and memory consolidation. During sleep, particularly REM sleep, the brain processes and organizes information learned throughout the day. Lack of sleep disrupts this process, leading to poorer retention and understanding.

Nick integrates these scientific insights with practical advice, making his blog an invaluable resource for optimizing learning strategies. He offers tips on improving sleep hygiene, such as maintaining a consistent sleep schedule, creating a restful environment, and avoiding stimulants before bedtime.

Nick also highlights the impact of disrupted sleep patterns, especially when attending international conferences. Jet lag and lack of sleep can severely hamper your ability to absorb new information. Moreover, alcohol consumption negatively affects learning, which is worth considering during conference social events.

Nick's post is packed with practical tips and impressive infographics that make the information easily digestible. It's a must-read for anyone involved in medical education or looking to optimize their learning strategies.

Aortic Emergencies: Key Insights from George Willis

George Willis, a renowned speaker and former professional American football player, presented on aortic emergencies at the St. Emlyn's Live Conference. His talk is a goldmine of information for emergency medicine practitioners. Aortic emergencies, such as ruptured aortic aneurysms and dissections, are critical conditions that require swift diagnosis and management.

George emphasizes using clinical history and tools like ultrasound to diagnose aortic emergencies. For example, ultrasound can identify abdominal aortic aneurysms and dissections via transthoracic echo. He also discusses managing these patients, particularly those with dissections, who present unique challenges due to their unstable blood pressure.

One notable case George describes involves managing pericardial effusion and tamponade resulting from aortic dissection. Techniques like pericardiocentesis can be life-saving, buying valuable time for definitive treatment. George's practical tips and real-world examples make his presentation an invaluable resource for anyone dealing with aortic emergencies.

Managing aortic emergencies requires a nuanced approach, particularly when dealing with unstable patients. George discusses using medications like labetalol for beta-blockade and alpha-blockade to manage blood pressure in dissection patients. These medications help reduce the strain on the aorta without compromising patient safety.

George also covers using imaging techniques, such as CT angiography, to confirm diagnoses and plan interventions. The ability to quickly and accurately diagnose these conditions is crucial for timely surgical intervention, which can significantly improve patient outcomes.

Ambulatory Care for PEs: Dan Horner's Expert Insights

Dan Horner returns with another insightful blog, this time on the ambulatory management of pulmonary embolisms (PEs). At the Arkham conference in Belfast, Dan discussed the benefits and challenges of treating PEs as outpatients. His post is a comprehensive guide to identifying which patients can be safely managed at home and which require hospital admission.

Dan explores various prognostic factors and scoring systems, such as PESI and sPESI, used to predict complications in PE patients. While these scores are better than Gestalt, they are not without limitations. Dan also touches on biomarkers and their role in predicting PE outcomes, though current data is not definitive.

Identifying patients who can be safely managed on an outpatient basis is crucial for optimizing resource use and improving patient comfort. Dan discusses the criteria for outpatient management, including the absence of hemodynamic instability, low bleeding risk, and adequate home support. These criteria help ensure that only patients with a low risk of complications are selected for ambulatory care.

Treatment options for PEs are evolving, with a shift from traditional anticoagulants like Warfarin to NOACs/DOACs. While these newer agents offer convenience, the evidence base is still developing. Dan also addresses the complexities of managing PEs in special populations, such as pregnant patients, highlighting the need for individualized care and informed discussions with patients.

Implementing ambulatory care for PEs requires careful planning and coordination. Dan provides practical advice on setting up ambulatory care pathways, including patient education, follow-up protocols, and the use of telemedicine to monitor patients remotely. He also discusses the importance of multidisciplinary collaboration in managing these patients.

Dan's blog is a treasure trove of resources, including guidelines for outpatient management, risk scores, and follow-up strategies. It's an essential read for anyone involved in the care of PE patients, offering the latest evidence and practical advice.

Coping with Clinical Tragedies: Liz Crowe's Personal Journey

To conclude our April roundup, we have two deeply moving blogs by Liz Crowe, where she shares her experiences of dealing with clinical tragedies. Liz's candid account of a recent tragic event in her professional life resonates with many healthcare professionals who have faced similar situations. Her blogs not only describe the emotional impact of these events but also offer strategies for coping and recovery.

Liz's first blog delves into the profound emotional toll that clinical tragedies can take on healthcare providers. She describes the initial shock, feelings of guilt and helplessness, and the long-lasting impact on mental health. These experiences are not uncommon in the medical field, where the stakes are high, and the outcomes can sometimes be devastating.

Liz emphasizes the importance of acknowledging and processing these experiences, rather than burying the emotions. She provides practical advice on how to support yourself, your colleagues, and your loved ones during such challenging times. Liz's insights are invaluable for anyone in the healthcare field, offering guidance on how to navigate the emotional aftermath of clinical tragedies.

In her second blog, Liz focuses on strategies for coping with and recovering from clinical tragedies. She highlights the importance of seeking professional help when needed, whether through counseling, peer support groups, or other mental health resources. Liz also emphasizes the value of self-care practices, such as exercise, mindfulness, and maintaining a healthy work-life balance.

Liz shares her personal journey of recovery, including the support she received from colleagues and the strategies that helped her regain her confidence and resilience. Her story is a powerful reminder that, while clinical tragedies are deeply challenging, it is possible to heal and continue to provide compassionate care to patients.

Liz's blogs also underscore the importance of building a supportive community within the healthcare profession. She advocates for open conversations about mental health and the emotional challenges of medical practice, fostering an environment where healthcare providers feel safe to share their experiences and seek help.

Liz's blogs are a must-read for anyone who has experienced or is supporting someone through a clinical tragedy. They offer hope and practical strategies for healing and moving forward.

Final Thoughts

April 2019 has been an incredibly insightful month on the St. Emlyn's blog. From groundbreaking research and practical medical education tips to deeply personal reflections on clinical tragedies, we've covered a wide range of topics. Each post offers valuable insights and practical advice for healthcare professionals.

As we continue to face the challenges of a busy emergency department, it's crucial to stay informed and up-to-date with the latest evidence and best practices. Whether you're managing septic shock, improving your learning strategies, diagnosing aortic emergencies, treating PEs, or coping with clinical tragedies, the St. Emlyn's blog has you covered.

The diversity of topics covered this month highlights the importance of continuous learning and adaptation in emergency medicine. By staying abreast of the latest research and best practices, we can ensure that we are providing the highest quality care to our patients.

Thank you for joining us on this journey through April 2019. We hope you find these posts as enlightening and helpful as we do. Stay tuned for more exciting updates and insights from the St. Emlyn's team. Enjoy your emergency medicine practice, and we'll speak to you again soon.

 

Ep 134 - March 2019 Round Up

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!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ep 133 - February 2019 Round Up

 

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.

Ep 132 - Aortic Emergencies with George Wills at #stemlynsLIVE

Back in late 2018 we gathered in Manchester for the inaugural #stemlynsLIVE conference. Our friend Dr George Wills gave a great talk on Aortic Emergencies.

All emergency physicians know that it's all to easy to miss an aortic catastrophe. Listen to George's wisdom on common pitfalls and top tips to make you a better emergency clinician.

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Also check out these excellent #FOAMed resources.

• Subscribe to the blog (look top right for the link)
• Subscribe to our PODCAST on iTunes
• Follow us on twitter @stemlyns
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• Find out more about the St.Emlyn’s team

Ep 131 - South African Emergency Medicine with Kat Evans at #stemlynsLIVE

Last year we were honoured to bring Kat Evans to Manchester to talk at the #stemlynsLIVE conference. We've covered emergency medicine in South Africa before on the blog, but there is no substitute to hearing about it from someone who actually works there.

Ep 130 - Critical Appraisal Nuggets: p-values

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!

Ep 129 - January 2019 Round Up

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!

Ep 128 - Can we use diagnostic probability to guide treatment thresholds in ACS with Charlie Reynard and Rick Body

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

Ep 127 - The Journey that Matters with Clare Richmond at #stemlynsLIVE

This podcast and presentation was recorded at the St Emlyn's LIVE conference in Manchester 2018. In this presentation Clare takes us through the rationale, principles, training and practice that we need in order to continually develop as prehospital and resuscitation practitioners.

You can read more from the event at http://www.stemlynsblog.org 

This is a great presentation for anyone interested in continually developing their own and their colleagues practice, delivered by someone who really knows what they are talking about and who works for one of the best developed resuscitation services in the world.

Clare is an Emergency Physician and specialist in Pre-Hospital Care and Retrieval medicine based in Sydney, with Royal Prince Alfred Hospital and Sydney HEMS. She has completed a fellowship in simulation based education, and enjoys training with “real” people - patients, bystanders and the other clinicians we come across as we treat our patients every day. She is a lecturer with the University of Sydney, and is involved in education for the NSW Institute for Trauma Injury Management. When Clare is not working on helicopters or training teams, she is studying yoga or hanging out with her puppy, Archie. 

Ep 126 - December 2018 Round Up

A Deep Dive into December: The Best of St. Emlyn’s Blog and Beyond

Welcome to the St. Emlyn’s Podcast! I’m Simon Carley, and today we’re going to journey through December 2018. This month has been filled with intriguing discussions, significant insights, and top-notch blogs from a variety of experts. As we wrap up the year and get ready to welcome 2019, it’s the perfect time to reflect on the key topics that have shaped our discussions around Christmas and the New Year.

Tribalism in Healthcare with Ross Fischer

First up, we have an insightful contribution from Ross Fischer, a key member of the St. Emlyn’s team and a Pediatric Surgeon based in Sheffield. Ross has delved into the topic of tribalism in healthcare, a subject we've explored previously but which remains ever relevant.

Tribalism refers to the formation of groups or 'tribes' based on common beliefs and cultures, which significantly influences our behaviour and treatment approaches in healthcare. Ross's blog revisits a remarkable presentation by Vic Brazil at SMACC Gold in 2014, highlighting how tribalism drives our interactions and behaviours within the medical field.

In healthcare, tribes often form around specialities – emergency physicians, surgeons, anaesthetists, etc. While having a strong group identity can be positive, it can also lead to unhealthy competition and misunderstandings. For example, emergency physicians might unfairly label surgeons as uncooperative, which is not only untrue but also counterproductive.

Ross's extensive experience across various medical cultures has given him a unique perspective on this issue. His blog emphasizes the importance of recognizing and mitigating tribalism to foster better cooperation and ultimately improve patient care. Some strategies he suggests include using personal names during referrals, face-to-face communication, being supportive rather than critical when things go wrong, organizing social events across specialities, and calling out tribalism in casual conversations.

Conservative Management of Chest Trauma

Next, I’ve put together a blog on the conservative management of chest trauma, inspired by several presentations I've done this year on torso trauma. The increasing body of evidence suggests that not all chest injuries, such as hemothoraces and small pneumothoraces, require invasive intervention.

Reflecting on my early days in emergency medicine, we operated under the strict guideline that any pneumothorax or hemothorax warranted a chest drain. However, advances in imaging technology, like whole-body CT scans, have revealed that many small pneumothoraces and hemothoraces were previously undetected and thus untreated without significant complications.

Recent studies, including a substantial observational study by Walker, support the safety of conservative management for many of these cases. This shift in practice aligns with our experiences here in Virchester, where we often opt to observe rather than immediately intervene with chest drains, even in ventilated patients. The evidence is still evolving, but it’s encouraging to see data supporting less invasive approaches.

Intensive Care Insights with Dan Horner

Dan Horner, Professor of Emergency Medicine at Virchester West, has shared three exceptional posts from our time at the Intensive Care Society conference in London. The interface between emergency medicine and ICU is a critical area, and Dan’s insights are invaluable for anyone interested in this field.

One standout topic from the conference was Tom Evans' presentation on exercise physiology. Though I missed it, the demonstration with Olympic rowers on stage, showcasing their lactate levels, was reportedly phenomenal. This type of hands-on demonstration highlights the extraordinary resilience and adaptability of human physiology, insights that are crucial for both emergency and intensive care practitioners.

In addition to exercise physiology, Dan and I covered the continuum of patient care from the roadside to critical care, emphasizing the importance of effective handovers and collaborative work with paramedics. Our discussions included the zero point survey, ATMIST handovers, and the significance of follow-ups to ensure paramedics receive feedback on their patients' outcomes, all crucial elements for improving patient care and professional practice.

FemInEM Conference Highlights with Natalie May

Natalie May wrapped up our review of the FemInEM conference, emphasizing the multifaceted nature of medicine. The themes of passion, role models, organization, consistency, persistence, mentorship, and leadership were central to the conference discussions. FIX19, the upcoming FemInEM event, promises to continue this tradition of exploring how medical professionals can impact not just clinical outcomes but also their own lives, colleagues, and the broader community.

HIV Management in Emergency Medicine

Gareth Roberts, a recent addition to our consultant team in Manchester, provided a comprehensive review of HIV management from an emergency physician’s perspective. His blog focuses on post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), critical areas for emergency physicians to master.

With the ongoing changes in HIV treatment and prevention, understanding the nuances of PEP and PrEP is vital. Gareth also touches on the rise of chemsex and its implications for emergency medicine, emphasizing the need for awareness and appropriate management strategies for patients involved in these practices.

Trauma Laparotomy: A Decade of Data

Rich Cardens explored the intriguing findings from his PhD research on trauma laparotomy. Despite significant advancements in trauma care over the past decade, the mortality rate for trauma laparotomy has remained unchanged. This surprising discovery prompts a deeper investigation into the factors influencing these outcomes.

Rich's research compares data from the JTTR military registry and the Royal London Hospital, highlighting the need for a comprehensive trauma emergency laparotomy audit. Understanding why mortality rates haven't improved could lead to better strategies and practices in trauma care.

Game of Thrones Mortality Study

For a lighter, yet still educational note, Janos Byan Beethar found an entertaining yet insightful study in the Injury Prevention Journal. This study analyzed the mortality of characters in Game of Thrones, a bit of fun that doubles as a critical appraisal exercise. With over half of the 330 characters meeting untimely deaths through injury, burns, or poisoning, the study offers a unique way to engage with epidemiological concepts and cause-effect associations.

Interestingly, the study also suggests that characters who change allegiances have a higher survival rate – perhaps a subtle hint at the importance of adaptability in both fictional and real-world scenarios.

Looking Ahead to 2019

As we close out December, it’s clear that 2018 has been a year of growth, learning, and exciting developments here at St. Emlyn’s. From addressing tribalism in healthcare to exploring conservative management strategies for chest trauma, and from the latest insights in intensive care to the evolving field of HIV management, our blogs have covered a wide range of critical topics.

We look forward to continuing this journey in 2019, bringing you the latest research, discussions, and insights in emergency medicine. Whether through our blogs, podcasts, or live events, we aim to foster a community of continuous learning and professional growth.

Stay connected with us on Twitter, Facebook, the blog, and the podcast. We’re here to support you in your practice and to ensure you stay at the forefront of emergency medicine. Here’s to another great year with St. Emlyn’s!

Ep 125 - November 2018 Round Up

 

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.

Ep 124 - Human factors, technology and humanity in critical care with Peter Brindley

This podcast was recorded at the Intensive Care Society State of the Art meeting in London 2018. Simon Carley interviews Prof Peter Brindley on the interface of technology, humans and humanity in critical care. The audio was recorded live and at the venue so there is a fair bit of background noise, but we hope that this does not distract from a wide ranging and fascinating podcast.

 

Ep 123 - Five strategies to improve your resuscitations with Simon Carley at #stemlynsLIVE

Five strategies to improve your resuscitations.

1. Zero point survey

2. Peer review

3. 10 in 10

4. Hot debriefs

5. Fly the patient

You can read about these strategies, watch the video and learn about the background on the St Emlyn's blog here https://www.stemlynsblog.org/stemlynslive-five-free-strategies-to-improve-your-resuscitation-practice-st-emlyns/ 

Ep 122 - Beyond ALS with Salim Rezaie at #stemlynsLIVE

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/ 

Ep 121 - October 2018 Round Up

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.

 

 

Ep 120 - The pursuit of excellence with Nat May at #stemlynsLIVE

 

This presentation was given at the inaugural #stemlynsLIVE conference on the 8th of October 2018 in Manchester. You can read more about the presentation and the conference here. https://www.stemlynsblog.org/in-pursuit-of-excellence/

Ep 119 - September 2018 Round Up

 

September Review: Key Insights from the Sentemlyns Podcast

Welcome to the latest edition of the Sentemlyns podcast blog. I’m Simon Carly, and today we're diving into the significant papers and events from September. We're a tad late this month due to the bustling activities surrounding the Sentemlyns conference and the Teaching Court course, both of which were tremendous successes here in Manchester. Stay tuned as we delve into the highlights of September, from groundbreaking studies to enlightening conferences.

Management of the Airway in Cardiac Arrest

Key Studies by Ashley Levy

We kick off with a comprehensive look at two pivotal papers by Ashley Levy, focusing on airway management in cardiac arrest. These studies, eagerly awaited by the medical community, provide critical insights into pre-hospital care.

Airways 2 Study

Published in JAMA in August, the Airways 2 study examined over 9,000 patients in the UK pre-hospital environment who suffered cardiac arrests. The study excluded patients who quickly returned to spontaneous circulation after a couple of shocks. The remaining patients were randomized into two groups: those receiving a supraglottic airway and those receiving an endotracheal tube.

Findings: The study revealed no significant difference in outcomes between patients who received endotracheal intubation versus those with a supraglottic device. This challenges the long-held belief that intubation is superior in cardiac arrest scenarios.

Implications: The findings suggest that in pre-hospital settings, the choice of airway device might be less critical than previously thought. It underscores the importance of managing ventilation effectively, regardless of the airway device used. For many practitioners, this means opting for the quickest and easiest airway device, typically a supraglottic airway. However, in prolonged or complex cases, converting to an endotracheal tube might still be preferable.

Laryngeal Tube vs. Endotracheal Intubation in the US Study

Another study published in JAMA, conducted in the US, compared endotracheal intubation with the use of a laryngeal tube. Similar to the Airways 2 study, it found no significant advantage to using an endotracheal tube. Interestingly, this study hinted at a slight benefit for the laryngeal tube, though this requires further investigation.

Conclusion: Both studies indicate that for pre-hospital cardiac arrest, the priority should be securing an airway quickly and effectively. While supraglottic airways may suffice in many cases, endotracheal tubes remain a viable option in more complex scenarios.

Global Health and Responsibility

Stefan Brujins’ Perspective

Stefan Brujins, a friend and colleague now working in the UK, provided a thought-provoking post on our responsibilities toward global health. Reflecting on his experiences growing up in South Africa, Stefan challenges us to reconsider our assumptions about equality and diversity in healthcare.

He directs us to an impactful presentation by Annette Alenio at SMACC, emphasizing the need for togetherness in global health. This presentation is a must-watch for anyone interested in global health, offering valuable insights on how we can contribute more effectively to the global medical community.

Highlights from the EUSEM Conference

Diverse Learning Experiences

The EUSEM conference, a combined event with the Royal College of Emergency Medicine, held in Glasgow, was a highlight of September. This event is renowned for its diversity and the unique learning opportunities it offers.

Treatment of Massive PE by Dan Horner

Dan Horner kicked off the conference with an insightful presentation on managing massive pulmonary embolism (PE). His update reflects the latest advancements and the complexities involved in clinical decision-making for thrombolysis in emergency settings. The emphasis on shared decision-making between clinicians and patients was particularly noteworthy.

European Simulation Cup Victory

Members of the Sentemlyns team joined the Royal College of Emergency Medicine team in the European Simulation Cup and emerged victorious. This competition, involving around 14 teams, culminated in a major incident simulation. The win was a testament to the team's skill and collaboration.

Narrative Learning and Storytelling in Emergency Medicine

Simon Carly’s Presentation

I had the opportunity to present on the use of narrative learning and storytelling in emergency medicine. While not a traditional clinical topic, the importance of engaging learners through storytelling cannot be overstated. Case reports, despite being viewed skeptically in literature, remain powerful tools for education when used correctly.

I drew heavily on the work of Jonathan Gottschall, particularly his book "The Storytelling Animal." Understanding the science behind storytelling can transform educational strategies, making them more effective and memorable.

Managing Sick Neonates

Natalie’s Comprehensive Guide

Neonates, with their unique physiology, often present challenges in emergency medicine. Natalie provided an excellent post on managing sick neonates, using the analogy of micro machines to explain various aspects of neonatal care. From glucose metabolism issues to identifying cardiac problems in premature babies, her guide is invaluable for practitioners who may not regularly deal with neonates.

Monkeypox Awareness

Janis Byombi’s Expertise

Monkeypox, a relatively obscure virus related to smallpox, has seen a recent outbreak with cases imported to the UK. Janis Byombi, our expert in international and tropical diseases, detailed the symptoms, diagnosis, and management of monkeypox. While generally self-limiting, awareness and proper handling are crucial, especially for healthcare workers who might be at risk.

RecessTO Conference Insights

Innovative Approaches to Learning

Ashley Liebergen shared her experiences from the RecessTO conference organized by Chris Hicks in Toronto. The conference's innovative approach combined traditional knowledge sharing with practical workshops and simulations, enhancing the overall learning experience. This method of building knowledge progressively throughout the day was particularly effective and engaging.

EMS Gathering in Ireland

Learning with Leisure

The EMS Gathering in Cork, Ireland, offered a unique blend of formal lectures and experiential learning. This “learning with leisure” approach took attendees to various locations around Cork for hands-on experiences, from airport emergencies to extrications.

Emotional Learning Experience One standout session was a cardiac arrest scenario staged in a theatre, focusing on the interaction between medical teams and the patient's relatives. This emotionally charged and theatrically presented scenario highlighted the importance of communication and empathy in emergency medicine.

Zero Point Survey

Enhancing Resuscitation Preparedness

Finally, I rounded off September with a post on the zero-point survey. This concept emphasizes that resuscitation begins before the patient arrives, utilizing the critical minutes from the initial alert to prepare thoroughly. This proactive approach can significantly improve resuscitation outcomes and efficiency.

Conclusion

September was a month of substantial learning and reflection for the Sentemlyns team. From groundbreaking studies in airway management to innovative approaches in global health and emergency medicine education, we've covered a broad spectrum of topics. As we look forward to October and beyond, we remain committed to bringing you the latest insights and developments in emergency medicine.

Thank you for joining us on this journey. Stay tuned for more updates and have a great day!

Ep 118 - August 2018 Round Up

St Emlyn’s Monthly Round-Up: August Highlights and Key Insights

Hello and welcome to the St Emlyn’s blog! I’m Simon Carley and today; I’m thrilled to share with you some of the standout moments and key insights from our blog in August. Yes, I know it’s October now, but we’ve been incredibly busy organizing the St Emlyn’s Live and the teaching course in Manchester. More on that in a later post. It’s been a fantastic period for us, and even though we’re a bit behind, it’s perfectly okay. Let’s dive into some spaced repetition and revisit the exciting content from August.

Natalie May’s Adventures Down Under

In August, we featured a series of blogs by Natalie May, chronicling her experiences at the Emergency Medicine of South-Os conference in Australia, where she served as a keynote speaker. Natalie covered several essential topics during her time there, providing valuable insights and lessons for emergency medicine professionals.

One of the key sessions she highlighted was about the effective use of apps in emergency medicine. This session was particularly interesting as it covered various clinical applications that can enhance productivity and patient care. Natalie shared top tips from her session, many of which she personally uses. This collection includes clinical tools and productivity apps, making it a must-read for anyone looking to optimize their practice. Many of these tips also tie back to a post by Scott Weingart from a few years ago about getting things done in emergency medicine. Natalie’s update builds on Scott’s foundation, providing new insights and practical advice for today’s busy and complex medical environment.

Lessons Learned at the Conference

Another highlight from Natalie’s posts was a session on lessons learned. This session brought together five respected professionals—Gary Birk, Jesse Spur, Natalie herself, Ian Summers, and Tim Lewinburg—who discussed instances where things didn’t go as planned. These stories weren’t just about clinical errors but also about soft skills, which, as we know, are anything but soft.

The panel covered communication issues, handover challenges, and awareness of equality and diversity in the emergency department. One poignant story involved an equality and diversity issue where Natalie acknowledged a consultation that didn’t go as expected. These discussions are crucial as they address elements that are challenging to learn from textbooks but significantly impact patient care and team dynamics.

Rick Body’s Troponin Insights

Moving on, we had an exceptional post by Rick Body on troponin, specifically focusing on high-sensitivity troponin samples. Rick is a leading authority on troponin, and his insights are invaluable. One particularly critical point he raised was the impact of biotin supplements on troponin assays.

Rick explained that patients taking biotin might show negative troponin results even when there is a myocardial infarction. This is a significant finding as it could lead to missed diagnoses. Rick advises emergency departments to either determine the type of analyzer their lab uses or routinely check biotin levels in patients to avoid potentially serious errors. This post is a must-read for anyone involved in emergency medicine as it provides practical advice to enhance diagnostic accuracy.

SMAC Conference and the CESR Route

August was also a month of anticipation for the upcoming SMAC conference. We discussed the excitement surrounding this event, which promises to be an incredible gathering of emergency medicine professionals. If you haven’t registered yet, make sure to do so as this will be the last SMAC, and it’s set to be unforgettable.

We also explored the CESR route in the UK. For those unfamiliar, the CESR (Certificate of Eligibility for Specialist Registration) is an alternative path to becoming a consultant in emergency medicine. Unlike the traditional six-year training program, the CESR route is portfolio-based and has recently undergone some changes. Gareth, who has successfully navigated this process and joined us as a consultant, shared his experiences and offered practical advice. His insights are particularly valuable for anyone considering this path, emphasizing the importance of early preparation and understanding the requirements.

Intravenous Fluids in Critical Care

One of the standout academic reviews we featured in August was on the use of intravenous fluids in critical care. Authored by Silam Lam, John Myberg, and Armando Bellomo, it provides a comprehensive overview of current best practices and evidence in fluid management.

The review highlights several key points. Firstly, the evidence base for most IV fluids is surprisingly weak, which is concerning given how widely they are used. The traditional approach of aggressive fluid resuscitation (fill them up until they can’t take any more) is now considered potentially harmful. Instead, a more cautious and mindful approach is recommended.

The review also discusses the importance of choosing the right type of fluid and adjusting the volume based on the type of shock. Dynamic assessment tools like point-of-care ultrasound are emphasized as they provide real-time insights into patient status, making fluid management more precise. The paper also touches on the role of the glycocalyx, an essential barrier between intravascular and extracellular fluid, which plays a critical role in fluid management during illness.

Avoiding Harmful Fluids

In addition to general fluid management principles, the review provides specific recommendations on which fluids to avoid. Hydroxyethyl starch solutions, for instance, should not be used, a point we have reiterated on the blog before. Gelatin, another fluid type, is also not recommended due to its limited benefits and potential risks.

Human albumin, although used more frequently in critical care, especially for conditions like sepsis, does not show significant advantages in most scenarios and should be avoided in traumatic brain injury. The ongoing debate between balanced solutions and normal saline is also addressed, with the review suggesting that balanced solutions may offer slight advantages in certain contexts.

Moral Injury in Emergency Medicine

Finally, we revisited a fantastic paper and podcast on moral injury by Esther Murray. This topic has resonated deeply with many in the emergency and critical care fields. The paper explores the psychological and emotional challenges faced by healthcare professionals, particularly those working in high-stress environments.

Esther’s discussion on moral injury—how the distress from perceived ethical transgressions impacts healthcare workers—is incredibly poignant. Given the increasing focus on mental health and well-being in our profession, understanding and addressing moral injury is crucial for sustaining our workforce. This small but significant study sheds light on an issue that many of us have experienced, even if we haven’t fully acknowledged it.

Wrapping Up August’s Highlights

August was indeed a month packed with valuable insights and crucial updates for the emergency medicine community. From Natalie May’s adventures and lessons learned to Rick Body’s troponin wisdom and the comprehensive review on intravenous fluids, there was a wealth of information to absorb and apply in practice.

We also delved into the practicalities of the CESR route, providing a roadmap for those considering this alternative path to consultancy. The discussion on moral injury, led by Esther Murray, reminded us of the importance of addressing the emotional and psychological well-being of healthcare professionals.

As we move into the latter part of the year, we look forward to bringing you more cutting-edge research, practical tips, and thought-provoking discussions. Stay tuned for the September podcast and the exciting content we have lined up from recent conferences. Thank you for being a part of the St Emlyn’s community, and here’s to continuing our journey of learning and improving patient care together.

Ep 117 - EMS Gathering 2018 with Aiden Baron

EMS Gathering round up 2018 with Simon Carley and Aidan Baron. See www.stemlynsblog.org Apologies for the sound quality on this one, it was all done in a fairly noisy environment.

Don't forget to listen to special guests from 23 mins onwards.

Ep 116 - Moral Injury in emergency and prehospital care with Esther Murray

This week we recorded a podcast inspired by a recent publication in the EMJ. Esther Murray aka @EM_Healthpsych is a psychologist working in London.

Her recent paper on whether the experiences of medical students might precipitate moral injury during their pre-hospital experiences gives  an insight into how we all cope with and respond to the clinical work we do. Some of the work we do is traumatic, painful and morally difficult to rationalise. We are witness to the very worst aspects of some of our patient’s lives and there may be a price to pay.

I was delighted to explore some of the concepts around moral injury in this podcast and would really recommend that you read the paper ¹ and consider whether this is something that can affect ourselves and our colleagues. The paper is open access at the moment so there is no excuse not to 😉

Although the paper is based on a small number of participants from only one aspect of the healthcare system it does recognise this limitation and alludes to future work with different groups of clinician.

What is Moral Injury?

Esther describes ‘moral injury’ as a concept emerging from work with military veterans. It is used to describe the psychological sequelae of ‘bearing witness to the aftermath of violence and human carnage

Ep 115 - July 2018 Round Up

 

The Sintervenants Podcast: July Highlights - Game Theory, PTSD, Epinephrine Trials, and More

Hello and welcome to The Sintervenants Podcast. I'm Simon Kelly, and today I’m going to guide you through the exciting developments in July. While we all enjoy the summer weather, there’s a lot more to discuss beyond vacations. Here’s what’s been happening in the world of emergency medicine.

Game Theory in Emergency Medicine: Finite and Infinite Games

This month, we delve into a fascinating post by my colleague, Craig Ferguson, about game theory and its application in emergency medicine. This concept revolves around finite and infinite games, an idea rooted in game theory, which you might recognize from the film A Beautiful Mind. The book it’s based on is also highly recommended for those interested in deeper insights.

Understanding Finite and Infinite Games

Finite games, such as chess, have known rules, defined endpoints, and players aware of their roles. Conversely, infinite games, like a soccer league, continue indefinitely. In these games, the objective is to stay in the game, continually evolving and adapting until resources are exhausted or other external factors intervene.

Application in Healthcare

In healthcare, particularly emergency medicine, Craig highlights the challenges posed by infinite games. Emergency medicine is an infinite game with no definitive endpoint. The objective is to keep going, continually providing care without a final goal. However, health service management often imposes finite rules, such as performance targets and time-based metrics. These finite measurements can clash with the infinite nature of healthcare, creating challenges and unintended consequences.

For example, measuring patient flow and quality of care through finite metrics in an emergency department doesn’t account for the complex, non-linear nature of healthcare systems. Changes in one area can lead to unforeseen issues in another, complicating the overall performance and outcomes.

Craig’s post has shifted my perspective on my shifts, especially during challenging times. It’s not about meeting arbitrary targets but understanding the infinite game we’re playing. Recognizing this can alleviate some pressure and help focus on continuous improvement rather than finite measures.

Rusty Carroll's Insights on PTSD

Another compelling post this month comes from Rusty Carroll, a clinician who has openly shared his journey with PTSD. His series, "Keep Walking: PTSD and Me," provides a candid look at the early stages of PTSD and the challenges of maintaining a facade of normalcy while dealing with underlying trauma.

The Reality of PTSD in Emergency Medicine

Rusty’s experience highlights the temptation and necessity for many clinicians to keep going despite severe emotional and psychological strain. The work-play-sleep-repeat cycle can mask serious issues, preventing individuals from seeking the help they need. This series aims to help those who haven't experienced PTSD understand the lived experiences of those who have, offering insights into coping mechanisms and the importance of addressing mental health openly.

Emergency medicine professionals often face traumatic events, making Rusty’s story particularly relevant. Understanding these experiences can foster empathy and support within the community, encouraging those struggling to seek help without fear of stigma.

The Controversy Over Epinephrine in Cardiac Arrest

In July, we also reviewed a significant trial on the use of epinephrine in out-of-hospital cardiac arrest, published in the New England Journal of Medicine. This British-led trial by the paramedic two collaborators, spearheaded by Gavin Perkins, has been highly anticipated due to ongoing debates about the efficacy of epinephrine (commonly known as adrenaline in Manchester) in such cases.

Key Findings of the Trial

The randomized controlled trial involved over 8,000 participants and focused on patients who had not responded to initial defibrillation. The primary outcome measured was the survival rate at 30 days, showing a survival rate of 3.2% in the epinephrine group compared to 2.4% in the placebo group.

While this suggests a significant benefit in terms of survival, the secondary outcomes raise ethical questions. Severe impairment, measured by the modified ranking scale, was more common among survivors in the epinephrine group. This finding complicates the interpretation of the results, as it indicates that while more patients survive, many suffer from severe neurological impairment.

Ethical Implications

The ethical dilemma here is whether increasing survival rates justifies the higher incidence of severe impairment. This question extends beyond medical practice into the realm of medical ethics and societal values. As clinicians, our goal is neurologically intact survival, aligning with public preferences for quality of life over mere survival.

Despite the trial’s insights, it doesn’t provide a definitive answer. As practitioners, we must weigh these findings carefully, considering the broader implications for patient care and quality of life.

Upcoming Events and Updates

Teaching Power Course

We’re excited to announce that the Teaching Power Course in October is almost sold out. By the time this post goes live, it might already be fully booked, which is fantastic news. This course, held in Manchester, promises to be a valuable learning experience for all attendees.

Sintervenants Live Conference

Tickets are still available for the Sintervenants Live Conference on October 9th. We’ve designed this event to be both affordable and enriching, featuring an international faculty that you won’t find at any other one-day course in the UK. Don’t miss this opportunity to join us for an exciting day of learning and networking.

Practical Insights: Managing Paronychia

Lastly, I’d like to highlight an insightful post by Natalie May on the management of paronychia. While not as high-profile as other topics, paronychia is a common and painful condition that we don’t always manage effectively in the ED.

Effective Treatment Strategies

Natalie’s review examines the formation of paronychia and the best treatment options. Our previous small randomized control trial suggested that lifting the nail fold is more effective than incision and drainage. Natalie’s findings support this approach, advocating for less invasive methods to alleviate pain and promote healing.

Key tips include soaking the affected area and using appropriate tools to lift the nail fold gently. For more severe cases, inserting a small wick can aid healing by allowing drainage without creating a new wound. Natalie also advises on recognizing conditions that mimic paronychia, such as osteomyelitis or tendon injuries, ensuring comprehensive and accurate treatment.

This practical advice can significantly improve patient care in emergency settings, providing quick relief and better outcomes for those suffering from this common ailment.

Conclusion

July has been a month of significant insights and developments in emergency medicine. From exploring game theory and its application in healthcare to understanding the complexities of PTSD and navigating the ethical dilemmas of epinephrine use in cardiac arrest, we’ve covered a wide range of topics.

These discussions underscore the dynamic and challenging nature of our field. By continually learning and adapting, we can improve our practices, support our colleagues, and ultimately provide better care for our patients.

Thank you for joining us on The Sintervenants Podcast. Keep an eye on our blog and podcast for more updates and insights. If you’re attending our events in October, we look forward to seeing you there. Until then, stay engaged, stay informed, and keep making a difference in the world of emergency medicine.

Ep 114 - The past, present and future of IV Fluids in Paediatric Practice with Steve Playfor

The Evolution of IV Fluid Therapy: A Critical Review

Welcome to St Emlyn's blog. Today, we explore the evolving landscape of intravenous (IV) fluid therapy in pediatric care. I'm Simon Carly, and I had the privilege of discussing this topic with Dr. Steve Playful at the Royal Manchester Children's Hospital. We delved into the historical context, current practices, and future directions of IV fluid therapy. Here's a comprehensive review of our discussion.

Historical Context of IV Fluids in Pediatrics

The use of IV fluids in pediatrics has undergone significant changes over the years. Approximately 20 years ago, the standard practice involved administering hypotonic fluids to children. This practice was rooted in research from the 1950s that misjudged children's electrolyte and fluid requirements, leading to widespread use of solutions like 0.18% saline with 5% glucose.

However, this approach had its drawbacks. While individual practitioners might not have frequently observed issues, numerous instances of iatrogenic hyponatremia leading to cerebral edema and death highlighted the risks. This spurred a reevaluation of IV fluid therapy practices in pediatrics.

Transition from Hypotonic to Isotonic Solutions

By the late 1990s, concerns about the dangers of hypotonic solutions grew. In 2006, the National Patient Safety Agency in the UK formed a group to address these concerns. They concluded that most children could safely receive half-normal saline as maintenance fluid, except in high-risk situations, marking a significant shift from previous practices.

The pediatric community started adopting isotonic solutions, such as normal saline. However, normal saline (0.9% sodium chloride) presents its own issues. Despite its name, it is not truly "normal" as its sodium content is slightly higher than plasma levels, and its chloride content is about 60% higher. Moreover, the pH of normal saline is around 5.5, far from physiological levels.

Emergence of Balanced Solutions

Balanced solutions have emerged as a promising alternative to both hypotonic and isotonic solutions. Designed to more closely mimic the body's natural plasma, solutions like Ringer's lactate and Plasma-Lyte have gained popularity in the UK. These balanced solutions are buffered with substances like acetate or gluconate to maintain a more physiological pH.

Plasma-Lyte, for instance, is available with and without dextrose, making it versatile for different clinical scenarios. These solutions are typically better tolerated and associated with fewer complications compared to normal saline.

The Debate: Saline vs. Balanced Solutions

The debate over the optimal type of IV fluid for pediatric patients continues. Recent studies, including large international trials, suggest balanced solutions are associated with fewer complications than normal saline. These complications include hyperchloremia, which can lead to acute kidney injury and other adverse outcomes.

Despite these findings, normal saline remains the most commonly administered IV fluid worldwide. This persistence is largely due to tradition and established practices. Changing these deeply ingrained habits requires substantial evidence and updated clinical guidelines.

Key Studies and Evidence

Several studies highlight the benefits of balanced solutions over normal saline. Research indicates that balanced solutions result in less acidosis and fewer chloride level shifts without demonstrated harm. However, not all studies show significant differences. The SPLIT trial, for instance, did not find a marked difference between the two fluid types, though this study had limitations, including uncontrolled pre-enrollment fluid administration and varying severities of illness among patients.

Future Directions in IV Fluid Therapy

As we look ahead, several areas of interest in IV fluid therapy emerge. One key question is which balanced solution is optimal for pediatric patients. Current options include fluids buffered with acetate and gluconate versus those buffered with lactate. Further research is needed to compare these solutions directly.

Another potential development is the inclusion of bicarbonates in balanced solutions. Stabilizing bicarbonates in plastic containers has been challenging, but advances in technology may eventually make this possible, offering a more complete balanced solution.

Practical Recommendations

For clinicians, the decision on which IV fluid to use should be guided by the latest evidence and tailored to the patient's needs. Here are some practical considerations and recommendations:

1. Review the Evidence: Stay informed about the latest research comparing saline and balanced solutions. Reflect on the pathophysiological basis for each type of fluid.

2. Consider the Patient's Condition: For most pediatric patients, balanced solutions are likely safer and more effective. However, specific clinical scenarios may require different approaches. For instance, patients with pyloric stenosis or certain nephrological conditions may benefit from tailored fluid compositions.

3. Monitor and Adjust: Fluid therapy should always be closely monitored and adjusted based on the patient's ongoing needs and responses. This includes considering electrolyte levels, acid-base balance, and overall clinical status.

4. Educate and Advocate: Part of the challenge in shifting to balanced solutions is overcoming established practices and resistance to change. Educate colleagues and advocate for evidence-based practices within your institution.

Conclusion

The evolution of IV fluid therapy in pediatrics mirrors broader trends in medical practice: the quest for safer, more effective treatments, and the need to challenge established norms with new evidence. While much remains to be learned, current evidence strongly supports the use of balanced solutions over traditional saline in most pediatric scenarios.

As clinicians, it's our responsibility to stay informed and adapt practices based on the best available evidence. By doing so, we can improve patient outcomes and advance the field of pediatric medicine.

For those interested in further reading, many of the studies discussed are blogged about on our site. Explore these resources for more detailed discussions and links to original research. Stay informed, stay curious, and continue striving for excellence in your practice.

Thank you for joining us on this deep dive into IV fluid therapy. We hope this discussion has provided valuable insights and practical recommendations for your clinical practice. As always, we welcome your thoughts and feedback on this important topic.

 

Ep 113 - The best of badEMfest 2018

Exploring the World of Emergency Medicine: Highlights from BadiM and Resuscitology Conferences

Welcome to the St Emlyn's podcast! Today, we're diving into the exciting and insightful experiences from recent conferences in the world of emergency medicine. Join us as we explore the key takeaways and reflections from the BadiM Conference in South Africa and the Resuscitology Conference in Australia. These events not only highlighted innovative approaches to emergency care but also fostered a sense of community and collaboration among healthcare professionals.

Setting the Scene: Weather and Warm Welcomes

As is customary, let's start with a quick weather update. It was a pleasant 16 degrees in Verchester, and similarly, New South Wales enjoyed beautiful blue skies at 16 degrees. The crisp air and clear skies set a perfect backdrop for our discussions on the latest developments in emergency medicine.

BadiM Conference: A Unique Experience in South Africa

The BadiM Conference in Greaten, South Africa, was a truly remarkable event. Located about two hours east of Cape Town, the conference was set in the picturesque hills, creating a beautiful and serene environment for learning and networking. This residential conference was a blend of a festival and a professional gathering, fostering a sense of community among attendees.

Building a Festival of Ideas

One of the standout aspects of the BadiM Conference was its emphasis on community and co-creation. Attendees camped in tents, shared meals, and engaged in discussions in large TP-style tents. This setting broke down traditional power hierarchies and encouraged open and honest conversations. The conference aimed to build a festival atmosphere where learning extended beyond formal sessions to informal interactions over coffee or drinks.

Addressing African EMS Challenges

The conference kicked off with a focus on African EMS and the unique challenges faced in delivering emergency care in resource-limited settings. Haikert's talk on African solutions for African problems was particularly enlightening. She emphasized the importance of developing context-specific solutions rather than applying models from high-income countries directly to African contexts. This approach highlighted the need for mutual learning and collaboration, ensuring that solutions are relevant and sustainable.

The Concept of Relief Porn

A thought-provoking concept discussed was "relief porn," which refers to the well-intentioned but often misguided efforts of delivering aid without considering long-term sustainability. The idea is to avoid short-term fixes that may not integrate well into existing systems. Dave Drew's discussion on teaching BLS underscored the importance of building comprehensive systems rather than isolated interventions.

Advocacy and Clinician Responsibility

Nat Fertil's talk on the role of clinicians as advocates resonated deeply. Drawing parallels between working in a war zone and addressing complex health needs in urban settings, she emphasized the importance of standing by patients who cannot advocate for themselves. This advocacy extends beyond clinical care to addressing social determinants of health.

The Gender Unicorn: Caring for LGBTQIA Patients

Caleb Lachnitz's talk on the Gender Unicorn and caring for LGBTQIA patients was a highlight. He stressed the need for healthcare providers to understand and respect diverse gender identities and expressions. The Gender Unicorn graphic, which differentiates between gender identity, gender expression, sex assignment at birth, and attraction, was a valuable tool in fostering better understanding and care for LGBTQIA patients.

Day Two: Workshops and Practical Learning

The second day of the BadiM Conference was workshop-focused, providing hands-on learning opportunities.

Feedback in Tricky Circumstances

We conducted a workshop on giving feedback in challenging situations. This session aimed to equip participants with skills to provide constructive feedback, even in difficult scenarios. We discussed techniques for addressing behavioral issues and ensuring feedback is productive and empowering.

Treating Pregnant Patients and Pediatric Emergencies

Penny Wilson's talk on treating pregnant patients was reassuring, emphasizing that treating the mother is often in the best interest of the baby. Ross Fisher's engaging session on pediatric emergencies, specifically addressing foreskin issues, provided practical insights for managing these conditions in the emergency department.

Tracheostomy Emergencies in Children

A session on tracheostomy emergencies in children, led by James Booth and his team, highlighted the importance of patient education and family collaboration. In settings where community services may be limited, working closely with families is crucial to managing chronic health problems effectively.

Ophthalmology and Trauma Care

Ophthalmology in remote settings and trauma care were also significant topics.

Innovative Ophthalmology Solutions

William Mapperman's presentation on using the Vula app for managing eye problems in remote areas showcased the power of electronic media in enhancing healthcare delivery. This app has significantly improved the quality of eye care across South Africa and other African nations.

Chest Trauma and Autotransfusion

Tim Hardcastle's discussion on chest trauma and the use of drains for autotransfusion was enlightening. This technique, which involves collecting and retransfusing blood from a hemothorax, is a practical solution in resource-limited settings with high rates of penetrating trauma.

Managing Coagulopathy and Intubation in Shocked Patients

Debates on managing coagulopathy and intubating profoundly shocked patients provided valuable insights. Emphasizing the importance of doing the basics well, such as using TXA and maintaining temperature, was a key takeaway. For intubation, using low doses of ketamine and high doses of rocuronium, along with preparing for cardiovascular collapse, were highlighted as best practices.

Human Factors and Emotional Resilience

Human factors and emotional resilience were recurring themes throughout the conference.

The Impact of Violence and Trauma

Dom Pinnick's talk on gangs and domestic violence in South Africa shed light on the broader societal impact of violence. The discussion underscored the need for emergency departments to be prepared for the complex emotional and physical needs of these patients.

Sleep Hygiene and Self-Care

Natalie May's session on sleep hygiene was a timely reminder of the importance of self-care. Sharing personal experiences and practical tips, she highlighted the universal challenges of sleep deprivation in the medical profession and offered strategies to improve sleep quality.

Super Bosses: Leading with Compassion

Sardlery's talk on being a "super boss" resonated with many. Emphasizing the importance of amplifying the talents of team members and creating a positive environment, he highlighted the role of compassionate leadership in emergency medicine.

Final Day and Closing Reflections

The final day of the BadiM Conference was a half-day, focusing on simulation workshops and additional learning opportunities.

Simulation Workshops and Major Incident Management

Simulation workshops, including a major incident workshop, provided hands-on learning experiences. Discussions on managing major incidents, such as the Manchester bombing and a fuel tanker explosion in Mozambique, highlighted the importance of having a common language and system for emergency management.

Venomous Plants and Animals

A workshop on venomous plants and animals featuring actual snakes and spiders added a unique and context-specific element to the conference. Understanding local environmental hazards is crucial for providing effective emergency care in different regions.

Organ Donation and Cruise Ship Medicine

Dave Thompson's session on organ donation in South Africa and Caroline Lewis's talk on working on cruise ships provided diverse perspectives on emergency medicine. These sessions emphasized the need for specialized skills and adaptability in various medical settings.

Personal Stories and Patient Safety

Kirsten Kingma's personal story of crashing a paraglider and subsequent injuries provided a poignant reminder of the vulnerability of healthcare providers as patients. Her insights into the patient experience underscored the importance of empathy and effective communication in healthcare.

Resuscitology Conference: Reflective Learning in Australia

The Resuscitology Conference, organized by Cliff Reed, was another standout event. Held in the Blue Mountains of Australia, this residential course focused on case-based reflective learning.

Case-Based Learning and Human Factors

Participants brought challenging resuscitation cases, which were discussed in detail using the STEPS approach (Self, Team, Environment, Patient, System). This method facilitated deep learning and practical problem-solving.

Fresh Air Life and Wellness

The concept of "Friluftsliv" (fresh air life) was integrated into the conference, encouraging outdoor activities and wellness. This holistic approach to learning and self-care was well-received by participants.

Breaking Bad News and Debriefing

One significant takeaway was the idea that breaking bad news does not always have to be the responsibility of the treating clinician. This team-based approach allows for emotional support and cognitive load sharing. The importance of debriefing and support for team leaders was also emphasized.

Looking Ahead: Future Conferences and Learning Opportunities

As we reflect on these enriching experiences, we're excited about upcoming events. The St Emlyn's Live Conference on October 9th promises to be another exceptional gathering, featuring keynote speakers Natalie May and Claire Richmond from Sydney HEMS. Additionally, the Teaching Co-op Course will offer a masterclass in medical education, focusing on practical skills for bedside teaching and departmental learning.

For those interested in Resuscitology, the next event is scheduled for November 15th and 16th. This innovative course will continue to build on the success of its inaugural session, providing a platform for reflective learning and collaboration.

The Value of Conferences in Emergency Medicine

While conferences can sometimes be seen as mere gatherings, the evolving quality and focus on interactive, participant-driven content have transformed them into valuable learning experiences. Events like BadiM and Resuscitology highlight the importance of community, collaboration, and continuous improvement in emergency medicine.

Thank you for joining us on this journey through the world of emergency medicine conferences. We hope to see you at future events, whether in Manchester or Sydney and continue to learn and grow together. Until then, enjoy your practice, stay curious, and keep pushing the boundaries of emergency care.

Ep 112 - Acute Psychiatric Emergencies in the ED.

 

The Importance of Acute Psychiatric Emergencies Training: Insights from the St Emlyn's Podcast

Introduction

Welcome to the St Emlyn's blog, where we delve into the latest topics and developments in emergency medicine. Today, we explore a crucial yet often overlooked aspect of our field: acute psychiatric emergencies. This post summarizes a recent conversation between Simon Carley and Kevin McRey Jones, highlighting the significance of addressing psychiatric emergencies within emergency departments. We will shed light on the Apex course, its methodologies, and the vital need for integrating psychiatric care into emergency medicine.

Addressing the Gap in Psychiatric Emergency Care

Kevin McRey Jones, a key figure in emergency medicine, recently joined the St Emlyn's podcast to discuss the Apex course, an initiative designed to fill a significant gap in emergency medicine training. Despite considerable advancements in managing various medical emergencies, psychiatric emergencies often remain underemphasized.

The Apex course addresses this gap by focusing specifically on acute psychiatric emergencies. Kevin explained that while many advancements have been made in managing cardiac, trauma, and obstetric emergencies, psychiatry has not received the same systematic approach. This has led to a fragmented care model where physical and psychological components are often treated separately.

The Origins and Purpose of the Apex Course

The Apex course, originating in 1992 with the Advanced Life Support Group, was created to systematize the training for managing acute psychiatric emergencies. Kevin, who has a long history of organizing and delivering courses in emergency medicine, emphasized the need for a unified approach to patient care. The course aims to bridge the gap between emergency physicians and psychiatrists, promoting a co-ownership model of patient management.

Why Psychiatric Emergencies are Often Overlooked

One major reason psychiatric emergencies have not received the same attention as other medical emergencies is the perception that these are problems best handled by psychiatrists or liaison nurses. This mindset leads to a tendency to pass psychiatric cases off to specialists rather than integrating psychiatric care into the emergency department's responsibilities.

Kevin highlighted a common issue where patients with both physical and psychological illnesses are often divided into two separate cases: the physical bit managed by emergency physicians and the psychological bit by psychiatrists. This division can lead to suboptimal care and poor outcomes, as the interconnected nature of these issues is overlooked.

The Consequences of Ignoring Psychiatric Components

Ignoring the psychiatric component of patient care can have severe consequences. Kevin pointed out that patients with psychiatric diseases often have poor outcomes regarding their physical health. This is largely because their physical ailments can be neglected due to the focus on their psychological issues.

Simon added that the outcomes for patients with psychiatric diseases, in terms of their physical health, are often terrible. This emphasizes the need for a more integrated approach to patient care, where both physical and psychological aspects are managed simultaneously.

The Need for Integrated Care

Kevin stressed the importance of co-owning the problem rather than treating psychiatric emergencies as the sole responsibility of psychiatrists. By doing so, emergency departments can provide more comprehensive care, addressing both physical and psychological needs. This integrated approach is essential for improving patient outcomes and ensuring that all aspects of a patient's health are considered.

Common Practices and Their Pitfalls

Simon discussed a common practice in emergency departments where patients presenting with apparent psychiatric problems are often assessed solely for physical issues before being referred to psychiatric specialists. This "clear them medically" approach can lead to delays in psychiatric care and inadequate management of the patient's overall condition.

Kevin acknowledged this issue and emphasized the need for emergency physicians to be involved in the psychiatric assessment and management of these patients. This approach ensures that all aspects of the patient's health are addressed, leading to better outcomes.

Rethinking Emergency Care for Psychiatric Patients

Simon reflected on the current practices and highlighted the need for change. The idea of dividing patient care into physical and psychological components, with little overlap, is increasingly seen as problematic. Kevin agreed, noting that sometimes organic problems can be overlooked when patients are quickly referred to psychiatric care without a thorough assessment.

The Apex Approach: AIOU Methodology

The Apex course introduces the AIOU methodology, designed to integrate psychiatric and medical care seamlessly. This structured approach includes:

• A: Assessment of aggression and agitation.
• E: Environment in which the patient is assessed.
• I: Intent of the patient, including suicidal ideation or harm to others.
• O: Objects the patient may use to carry out their intent.
• U: Unified assessment, combining both physical and psychological evaluations.

Implementing the AIOU Methodology

Kevin explained that the AIOU methodology is a co-created approach by psychiatrists and emergency physicians. This collaboration ensures that both physical and psychological aspects of patient care are addressed. The methodology aligns with the primary assessment, resuscitation, and definitive care phases familiar to emergency physicians.

Addressing Challenges in Psychiatric Emergency Care

Rapid tranquilization is a common concern in managing psychiatric emergencies. Kevin emphasized that the goal is to use the minimum level of intervention required, whether that involves oral medication or, if necessary, safe rapid tranquilization. The course teaches a balanced approach to ensure patient safety and effective management.

The Role of Risk Assessment

Psychiatry is a risk-driven specialty, focusing on assessing risks of violence, flight, and harm to self and others. Kevin highlighted the importance of minimizing these risks through a structured, systematic approach. This methodology allows for a comprehensive evaluation and management plan that addresses both immediate and long-term risks.

Structured Approach to Both Psychiatric and Physical Assessment

The Apex course emphasizes a structured approach to both psychiatric and physical assessments. This dual-focus ensures that all aspects of a patient's health are considered, leading to more comprehensive and effective care.

Collaboration Between Psychiatrists and Emergency Physicians

The course promotes collaboration between psychiatrists and emergency physicians, encouraging them to learn from each other and develop joint solutions to patient care challenges. This partnership is essential for providing holistic care and improving patient outcomes.

Co-Assessment and Risk Management

The course highlights the importance of co-assessment and risk management. By working together, psychiatrists and emergency physicians can provide a more unified approach to patient care, addressing both physical and psychological needs simultaneously.

Substance Abuse and Psychiatric Symptoms

Substance abuse often complicates psychiatric emergencies. The Apex course takes a symptom-based approach, focusing on the specific challenges presented by patients with delirium, confusion, aggression, and self-harm. This approach allows for a more tailored and effective management plan.

Prevalence and Importance of Addressing Psychiatric Emergencies

Psychiatric emergencies are more common than many realize. Kevin noted that about 5% of patients in emergency departments present with direct psychological or psychiatric symptoms. Including substance abuse and alcohol-related cases, this number can rise significantly. Addressing these emergencies systematically is crucial for improving patient care and outcomes.

Conclusion

The Apex course represents a significant advancement in the training and management of acute psychiatric emergencies. By promoting a unified approach to patient care, it addresses a critical gap in emergency medicine. Collaboration between psychiatrists and emergency physicians is essential for providing comprehensive care and improving patient outcomes. For more information on the Apex course and upcoming training sessions, visit the Advanced Life Support Group's website.

Final Thoughts

Reflecting on the discussion, Simon emphasized the importance of integrating psychiatric care into emergency medicine. The dichotomy approach, where physical and psychological issues are treated separately, is increasingly seen as inadequate. The Apex course offers a pathway to more comprehensive, patient-focused care, ensuring that all aspects of a patient's health are addressed.

How to Learn More

For those interested in learning more about the Apex course and upcoming training sessions, visit the Advanced Life Support Group's website at www.alsg.org. The course is offered in various locations, providing opportunities for emergency physicians and psychiatrists to enhance their skills and knowledge in managing acute psychiatric emergencies.

By embracing this integrated approach, we can ensure that patients receive the comprehensive care they need, improving outcomes and advancing the field of emergency medicine.

Ep 111 - April 2018 Round Up

St Emlyn's Podcast: April Review and Key Insights

Welcome to the St. Emlyn’s podcast, your monthly source for insightful discussions and reviews from the world of emergency medicine. I’m Iain Beardsell, and alongside me is Simon Carley. In this edition, we're diving into the posts we’ve covered on our blog in April. After a grueling winter, we are finally catching up. We’re recording this in May, and it's a significant achievement for us. Let’s delve into the highlights and key takeaways from April.

Catching Up with St. Emlyn’s

Firstly, Simon and I are thrilled to be back on track. The sun is shining, signaling the end of winter here in the UK, and we’re embracing the spring warmth. Before we dive into the specifics, Simon, you’ve been traveling quite a bit recently. Can you share some of your experiences?

Travels and Learnings from Graz, Austria

Simon: Indeed, Iain. Recently, I had the privilege of visiting Graz, Austria, a beautiful city where I was invited by the NordDoc and the Austrian Society of Emergency Medicine. We attended the ninth Congress, or as they say in German, "Abit's Goermanneshaft for Notfallmedizin." It was an enlightening experience, despite my initial challenges with the language.

The hospitality in Graz was exceptional, and the city itself is stunning. Emergency medicine in Austria is still in its nascent stages, but the enthusiasm and energy among the young physicians were palpable. The simultaneous translation during presentations was a unique experience. I also conducted sessions on feedback and ultrasound teaching, which were well-received.

Iain: That sounds incredible, Simon. It’s always inspiring to see how different countries are integrating emergency medicine into their healthcare systems. Let’s move on to the main topics we covered in April.

Key Highlights from April's Blog Posts

Feedback and Coaching in Emergency Medicine

Iain: One of the key discussions in April was about feedback and coaching, a topic Simon presented in Austria. Feedback is crucial for continuous improvement in emergency medicine. Simon, can you elaborate on your main messages from the talk?

Simon: Absolutely, Iain. Feedback is essential for growth, and there are three main types: appreciation, coaching, and evaluation. One common issue is when these types are confused. For instance, after a challenging night shift, if a consultant gives a detailed coaching session instead of simple appreciation, it can be demoralizing. It’s crucial to match the feedback to the context and needs of the receiver. This ensures the feedback is purposeful and effective.

Understanding Diagnostic Tests: Beyond Black and White

Rick's post from April 10th delved into the nuances of diagnostic tests, emphasizing that results are not merely positive or negative but often fall into a gray area. Simon, can you shed more light on this?

Simon: Diagnostic tests in emergency medicine are indeed complex. Take troponin levels, for instance. A troponin of 2000 is vastly different from a troponin of 15, although both might be labeled positive. Understanding the probabilistic nature of diagnostics is crucial. Rick's post does a fantastic job explaining this with examples, especially around acute coronary syndrome. We use a T-max calculator in Manchester to determine the likelihood of ACS based on various factors, including troponin levels. This probabilistic approach is vital for accurate diagnostics.

Lessons from the War: Insights from Ashley Liebig and Noah Galway

Another powerful post in April was Ashley Liebig's discussion with Noah Galway about their experiences during the Iraq war. Their insights provide a stark contrast to typical emergency department scenarios. Iain, what stood out to you in this post?

Iain: The personal bond formed between Ashley and Noah through shared traumatic experiences is profound. Unlike the typical patient-doctor dynamic in emergency departments, battlefield medicine creates a deep, enduring connection. This post reminded me that the emotional and psychological impacts of medicine are just as significant as the physical treatments. Noah’s journey, from experiencing trauma to achieving remarkable feats like participating in the US version of Strictly Ballroom, is truly inspiring.

Pediatric Trauma and the Use of Whole Body CT

We also discussed the use of whole-body CT in pediatric trauma patients. Simon, can you summarize the findings from this journal club article?

Simon: Certainly. Whole-body CT is a common practice in adult trauma but its utility in pediatric trauma is questionable. A multi-center cohort study from the National Trauma Data Bank in the US found that focused CT is often more appropriate for children. In Manchester, we rarely perform whole-body CTs on pediatric patients unless there's a significant mechanism of injury. The radiation risks and the lower incidence of severe injuries in children make focused CT a safer and more effective choice.

Complications of Anticoagulation: Managing Bleeding Risks

Dan Horner's professorial lecture on the complications of anticoagulation and how to manage them was another highlight. Simon, what were the key takeaways from Dan's talk?

Simon: The sheer number of patients on anticoagulants in the UK, approximately 660,000, underscores the importance of this topic. Bleeding is a significant risk, and managing it, especially with the newer DOACs, is challenging. Dan provided practical advice on handling bleeding complications, including when specific antidotes are unavailable. Understanding these risks and management strategies is crucial for emergency physicians.

Top 10 Trauma Papers: Insights and Innovations

In another significant event, I presented the top 10 trauma papers at the Trauma UK conference. This talk was later featured on the Resusary podcast with Simon Lang. It's always a pleasure to delve into the latest research and innovations in trauma care.

Iain: That sounds fantastic, Simon. For those interested, the blog post contains all the details and links to the podcast. If you have any suggestions or think we've missed some crucial papers, do let us know.

Penetrating Trauma in Philadelphia: Lessons from the Frontline

Zak Stein, who trained with us in Manchester and now works in Philadelphia, shared insights on penetrating trauma. Interestingly, patients arriving by police or private vehicle have higher survival rates compared to those transported by ambulance. Simon, what are your thoughts on this practice?

Simon: The practice in Philadelphia highlights the time-critical nature of penetrating trauma. Quick transport to the ED, even by police or private vehicle, can significantly improve survival rates. In the UK, scene times can be prolonged, especially if the scene is unsafe. This practice makes us reconsider our approach to time-critical conditions. It's a balance between ensuring safety and providing timely care.

The Resuscitationist’s Guide to Health and Wellbeing

Our final post in April was the launch of "The Resuscitationist’s Guide to Health and Wellbeing," a comprehensive resource compiled from our blog posts. Simon, this has been a significant project for you. Can you tell us more about it?

Simon: This book is part of our ongoing effort to promote wellbeing among emergency medicine professionals. It includes practical tips on managing night shifts, reflective pieces on coping with difficult situations, and much more. Wellbeing is one of the four pillars of St. Emlyn’s, along with the philosophy of emergency medicine, evidence-based medicine, and clinical excellence. We hope this book will be a valuable resource for our community. It’s available for free, so please read and share it widely.

Conclusion and Future Directions

April was a busy month for us at St. Emlyn’s, filled with travel, conferences, and insightful blog posts. We’re excited about what’s coming up in the future. We have a busy summer ahead, including the emergency surgical skills course with Caroline Leach in Manchester and our St. Emlyn’s live and teaching co-op course in October. Tickets are selling fast, so grab yours soon.

Before we sign off, a quick mention of the Bad E.M. Fest, which was a spectacular event. We’ll discuss it in more detail in future posts and podcasts. For now, you can read the four blog posts we’ve published about it so far.

Iain: It’s always fun to chat with you all. We hope everyone is enjoying the spring sunshine and looking forward to the summer. Simon, any final thoughts?

Simon: Just one, Iain. Are we the only emergency medicine podcast that talks about the weather at the beginning and end of every episode? It seems like the most British thing ever.

Iain: It's hugely important, Simon. Maybe next time, we’ll focus entirely on the weather! Until then, enjoy the sunshine and take care, everyone.

Thank you for joining us for this edition of the St. Emlyn’s podcast. Stay tuned for more insights and discussions, and don’t forget to check out our blog for the latest posts and updates.

Ep 110 - March 2018 Round Up

 

March 2018 Roundup: Evidence-Based Medicine and Exciting Announcements at St Emlyn's

Welcome to the Centeminine's podcast monthly roundup for March 2018! This post delves into key highlights from our blog, discussing critical topics in evidence-based medicine and sharing exciting upcoming events. Let's dive in!

Catching Up After Winter

As the harsh winter fades, we’re catching up with several important topics from March. Despite the seasonal lag, there's a lot happening in the world of evidence-based medicine. Our blog has been buzzing with insightful posts, and we encourage you to explore the rich content we have curated for you.

Exciting Upcoming Events

Before diving into March's blog posts, let's highlight some exciting events on the horizon. We are thrilled to announce St Emlyn's Live and the Teaching Course in Manchester. If you're planning your study leave for the next 12 months, these are opportunities you won't want to miss.

St Emlyn's Live

St Emlyn's Live is shaping up to be an unmissable event. Scheduled for October in Manchester, this event promises a blend of learning and fun, with the added bonus of Manchester's unique charm—where the sun always shines (psychologically and philosophically, if not literally). Check our website for more details and secure your spot. We’re putting immense effort into making this event exceptional, ensuring it’s worth both your time and money.

The Teaching Course in Manchester

Alongside St Emlyn's Live, we have our renowned Teaching Course in Manchester. As you consider your professional development for the year, keep in mind the benefits of attending a well-structured, impactful course like ours. We're confident you'll find it a valuable investment in your career.

Evidence-Based Medicine: The Great IV Fluid Debate

One of the standout topics in March has been the ongoing debate over IV fluids in critically ill patients. This subject stirs significant anxiety and diverse opinions across departments and even within the same hospital.

The Normal Saline vs. Balanced Fluids Debate

The crux of the debate revolves around whether to use normal saline or balanced fluids such as Hartmann's or Plasmalyte. The evidence to date has been mixed, leading to differing practices. Our colleagues down under published the SPLIT trial a few years ago, finding no significant difference, but the sample size at the time limited the conclusions.

Recent Trials in the New England Journal of Medicine

Recently, two significant trials published in the New England Journal of Medicine have shed more light on this issue. These trials investigated the effects of balanced crystalloid versus saline in critically ill patients and emergency department patients admitted to the wards.

Cluster Randomized Trials

The trials used a cluster randomized design, where units were randomized to administer either balanced crystalloid (lactated Ringer's or Plasmalyte) or saline for a period before crossing over. With over 15,000 participants in each study, the findings are quite robust.

Key Findings

The trials revealed a small but significant difference in major kidney events in the critical care group (14.3% vs. 15.4%), suggesting a potential benefit of balanced fluids. While the mortality difference was not as pronounced, these results could have important implications for global intensive care practices.

Practical Implications in Emergency Medicine

As emergency physicians, how do these findings influence our practice? Over the past few years, there's been a shift towards more frequent use of balanced solutions, driven by a sound physiological rationale. Although the exact clinical significance of hyperchloremic acidosis from saline remains debated, the pathophysiological argument for balanced fluids is compelling.

Local Practices and Preferences

In our practice, preferences vary. For instance, our neurointensive care unit favors saline for patients with specific neurological issues, as explained in a podcast with Dr. John Hell from Southampton. For general use, Hartmann's is often the go-to solution.

Teaching the Next Generation

We emphasize the importance of fluids in emergency medicine to our new doctors. With only four main treatments—oxygen, analgesia, antibiotics, and fluids—it’s crucial to administer fluids effectively. While the choice of fluid might not be critical initially, ensuring the right volume is given can make a significant difference.

The Teaching Course in Cape Town

Another highlight from March was the successful teaching course in Cape Town. This course will be replicated later this year in Manchester, offering an excellent opportunity for hands-on learning and professional growth.

Success in South Africa

The Cape Town course was a resounding success, providing valuable insights and skills to all participants. The feedback was overwhelmingly positive, highlighting the course's effectiveness and the enriching experience it provided.

Chris Weymouth’s Experience

Chris Weymouth, a UK-trained physician, shared his experience working in a rural South African hospital. His story underscores the importance of structured and well-supported international placements. Such experiences not only enhance clinical skills but also foster personal growth and resilience.

Cardiac Arrest: Predicting Outcomes with Pupil Responses

Our final major topic for March revolves around predicting outcomes in cardiac arrest, specifically through pupil responses. This topic, close to our hearts, is critical for making informed decisions during resuscitations.

The Study from France

A recent study from France, analyzing over 11,000 cardiac arrests, examined whether early pupil responses could predict outcomes. The findings were intriguing but not definitive.

Sensitivity and Specificity

The study found that the absence of a pupillary light reflex is a poor prognostic sign, but with only 72% sensitivity and 68.8% specificity, it’s not conclusive enough to base critical decisions on.

The Gray Areas in Resuscitation

Deciding when to stop resuscitation remains one of the most challenging aspects of emergency medicine. While some cases are clear-cut, many fall into a gray area, making it difficult to determine the right course of action.

ECPR and Prolonged Arrests

With emerging technologies like ECPR (Extracorporeal Cardiopulmonary Resuscitation) and reports of remarkable recoveries from prolonged arrests, the decision to stop becomes even more complex. In young patients with no prior morbidity, the stakes are even higher, and the decision requires careful consideration and often consultation with colleagues.

Upcoming Events and Final Thoughts

As we wrap up our March roundup, we look forward to several upcoming events and ongoing discussions. The St Emlyn's team will be speaking at the Retrieval Conference in Scotland in April, and we have a variety of summer events lined up.

Join Us at St Emlyn's Live

Don't forget to join us at St Emlyn's Live in October. This event promises to be a highlight of the year, offering a blend of cutting-edge medical insights and networking opportunities. Check our website for all the details and secure your spot today.

Stay Tuned for More

We'll be back in May with updates on April's posts and more engaging content. Until then, keep enjoying your emergency medicine practice, take care of yourselves and your patients, and stay connected with the St Emlyn's community.

Conclusion

March has been a month filled with significant developments in evidence-based medicine, exciting course announcements, and thought-provoking discussions. As always, our goal is to provide you with the best possible insights to enhance your practice and support your professional growth. Thank you for being part of the St Emlyn's community. We look forward to engaging with you through our blog, podcasts, and upcoming events.

Ep 109 - The Physican Response Unit (PRU) with Rich Carden and Tony Joy

The Physician Response Unit (PRU) is an innovative service in East London that takes the emergency department to the patient. The PRU is led by Tony Joy, consultant in emergency medicine and prehospital care and is a fairly unique service to the UK.

In this podcast our very own Richard Carden interviews Tony for an in depth understanding of how the service is supporting the entire emergency care system in London.

You can read more about the PRU here https://londonsairambulance.co.uk/our-service/news/2017/10/remodelled-pru-to-be-a-seven-day-service-for-the-first-time and look out for a blog post on the St Emlyn's blog site very soon.

Ep 108 - February 2018 Round Up

 

 

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.

Ep 107 - January 2018 Round Up

Surviving a Relentless Winter: Reflections and Insights from St. Emlyn's

Welcome Back to the St. Emlyn's Podcast

Welcome to the St. Emlyn's podcast. I'm Iain Beardsell, and I'm Simon Carley. We are delighted to be back with you after what can only be described as a rather tricky winter. The winter season has always been challenging for emergency departments across the UK, but this year felt especially relentless. In this blog post, we will reflect on the past few months, share key insights, and look forward to exciting events on the horizon, including the St. Emlyn's Live conference.

The Winter Struggle: A Nationwide Challenge

Down south in our emergency department, we have faced significant challenges. Iain shared his experiences: "We have been having a heck of a time. It has been a real struggle. I'm utterly exhausted, and it has only been in the last couple of weeks that it felt like we could breathe again." The situation has been similarly difficult up north. Simon echoed these sentiments: "It's been a bit grim up north, to be honest. This winter felt different, harder. The emergency departments in the UK have always had problems over winter, but it has felt more relentless this year."

Unprecedented Pressure and Relentless Demand

We didn't have much of a summer to recuperate, and the winter was relentless day in and day out. Our department saw unprecedented pressure, with patient numbers pushing us to our limits. Interesting statistics from our department showed consecutive days of being over capacity, creating concerns about patient care and safety. Despite the exhaustion, we managed to maintain a high standard of care, with complaints remaining at normal levels and even receiving more compliments than usual.

Coping Strategies and Positive Outcomes

Maintaining patient care while looking after ourselves has been a challenge. We have implemented various strategies to keep on track, from educational events to incredible clinical work. Reflecting on our achievements, Simon highlighted the importance of continuing education and maintaining healthcare standards even under pressure. "We have done some amazing things over the winter, and it is something we can be really proud of," he said.

Understanding Public Perception and Political Activity

The public's understanding of the pressures in the healthcare system has increased, although tolerance for the challenges faced remains limited. Political activity over the winter saw clinical leads writing to the Prime Minister, and emergency medicine frequently made the front pages of newspapers. However, recent events, such as the nerve agent attack in Salisbury, have shifted the focus away from A&E crowded corridors, providing some relief.

Looking Forward to St. Emlyn's Live

We have many exciting events coming up this year, including the highly anticipated St. Emlyn's Live conference. Scheduled for Tuesday, the 9th of October in Manchester, this one-day conference will bring us out from behind our microphones and keyboards to present live. The event promises to be hugely cost-effective, with an incredible lineup of speakers from around the world, including Claire Richmond from Sydney Hems, Natalie May, Salim Rezy from the US, and Kat Evans from South Africa.

Interactive Learning and Cost-Effective Education

We have designed St. Emlyn's Live to be an interactive conference, reflecting everything we aim for in our podcasts and blogs. The conference is priced at £150 for consultants, with discounts available for trainees, registrars, doctors in training, allied health professionals, nurses, and medical students. Given the limited venue size, we expect tickets to sell out quickly, so we encourage early booking.

Post-Conference Teaching Course

For those looking for more in-depth learning, we are hosting a teaching course on the 10th and 11th of October, directly after the conference. This course focuses on practical education techniques, helping clinician educators improve their teaching skills. It has been highly acclaimed by previous participants, offering a transformative learning experience.

Reflecting on Clinical Medicine and Evidence-Based Practice

At St. Emlyn's, we value reflection and evidence-based practice. In January, we covered several important topics on our blog, including devastating brain injuries, dizzy patients, and the adrenal trial. Let's delve into these discussions and see what we can learn.

Devastating Brain Injuries: Updated Guidance

One of the critical topics we discussed was devastating brain injuries. Historically, decisions about the prognosis of patients with severe traumatic injuries or subarachnoid bleeds were often made too quickly, based on initial CT scans. However, recent guidance suggests that we should not make precipitous decisions about patient outcomes solely based on early imaging.

In summary, it's essential to give these patients at least 24 to 72 hours before making a prognosis. This allows time for clinical outcomes to become more apparent. In our hospital, we transfer these patients to neuro-intensive care and have a proactive organ donation program, ensuring patients and their families receive the care they deserve.

Differentiating Dizziness: Central vs. Peripheral Causes

Another challenging area in emergency medicine is dealing with patients presenting with dizziness or vertigo. Differentiating between central causes, such as posterior circulation strokes, and peripheral causes can be difficult but crucial. We highlighted the importance of understanding the difference and utilizing tests like the HINTS exam to aid diagnosis.

As emergency physicians, we must continue to educate ourselves on these diagnostic tools. Utilizing resources like the St. Emlyn's blog, YouTube, and FOAMed can help us stay updated and improve patient care. It's essential to be comfortable revisiting and revising our knowledge to ensure accurate diagnoses and appropriate treatment plans.

The Importance of Reflection in Medical Practice

Reflection is a powerful tool for lifelong learning and self-improvement. Despite recent controversies, such as the case involving a junior doctor in Leicester, we must not abandon reflection. It helps us increase self-awareness, think critically about our practices, and improve our clinical skills.

Natalie May's blog post on reflection emphasizes that it's not just about ticking boxes but about purposeful and structured thinking. Her insights from Sydney Hems highlight the importance of integrating reflection into our daily practice to enhance our growth as clinicians.

The Adrenal Trial: Steroids in Septic Shock

The adrenal trial, reviewed by Dan Horner, examined the use of steroids in septic shock. Published in the New England Journal of Medicine, this trial aimed to determine whether steroids improve outcomes in these patients. The results showed no significant difference in mortality, although some secondary outcomes, such as vasopressor use and ICU days, showed variations.

The trial highlights the complexity of medical treatment and the need for continuous learning and evaluation. It reminds us that while some treatments may show promise, their benefits might not always be clear-cut. This underscores the importance of evidence-based practice and staying informed about the latest research.

Embracing Continuous Learning and Collaboration

Emergency medicine is a dynamic and ever-evolving field. At St. Emlyn's, we are committed to continuous learning, sharing knowledge, and improving patient care. The challenges of winter have tested our resilience, but they have also shown the importance of collaboration, education, and maintaining high standards of care.

We encourage our readers and listeners to stay engaged with our content, participate in upcoming events, and continue striving for excellence in their practice. The St. Emlyn's Live conference and the teaching course are excellent opportunities for professional development and networking with peers from around the world.

Conclusion: Looking Ahead with Optimism

As we move forward into the spring and summer, let's take a moment to reflect on the lessons learned and the progress made. The past winter was tough, but it also demonstrated our ability to adapt, innovate, and support one another. With exciting events like St. Emlyn's Live on the horizon, we have much to look forward to.

Thank you for being part of the St. Emlyn's community. Stay connected, stay curious, and let's continue to learn and grow together. Here's to a bright and hopeful future in emergency medicine.

Ep 106 - Debriefing in Critical Care with Liz Crowe

 

The Importance and Practice of Debriefing in Emergency and Critical Care

Debriefing is a crucial process in healthcare settings, particularly in emergency and critical care units. It involves structured discussions following critical events to help teams learn from their experiences and support each other's psychological well-being. This process is not just about operational reflection but also about addressing the emotional impact of challenging situations on healthcare professionals.

Understanding Debriefing

Debriefing can take two primary forms: hot debriefs and formal debriefs. Hot debriefs occur immediately after an event and focus on operational aspects, such as what happened, what went well, and what could be improved. They are concise and do not delve into the psychological aspects of the incident. These debriefs are valuable for capturing immediate lessons and determining if further, more comprehensive discussions are necessary.

Formal debriefs, on the other hand, are conducted five to seven days post-event. This delay allows participants to process initial emotions, making it a more suitable time for in-depth discussions. Formal debriefs cover both operational details and psychological reactions, providing a safe space for staff to express their feelings and thoughts. They are essential for long-term learning and emotional healing, ensuring that the team can move forward positively.

Timing and Setting

The timing of debriefing is critical. While hot debriefs capture immediate reflections, formal debriefs should not be rushed. Conducting them too soon can be ineffective, as participants might still be too emotionally charged to engage constructively. In our hospital, formal debriefs are usually organized when an event causes significant distress among the staff, whether due to a clinical situation, a tragic incident involving a colleague, or a complex ethical dilemma.

The setting for a debrief should be carefully chosen to ensure a conducive environment for open communication. We often use teaching rooms, which are formal enough to maintain the seriousness of the discussion but comfortable and private enough to encourage honesty and confidentiality.

Facilitators and Structure

Selecting the right facilitators is crucial for a successful debrief. Typically, a social worker, like Liz, and a senior medical consultant co-facilitate. The consultant provides a comprehensive overview of the clinical aspects, while the social worker manages the psychological and emotional discussions. This balance ensures that all relevant facets of the event are covered.

A formal debrief generally follows a structured format:

1. Introduction and Ground Rules: The facilitator sets the stage by explaining the purpose of the debrief and establishing ground rules, such as maintaining confidentiality and focusing on constructive feedback.

2. Narrative of the Event: A detailed recount of the incident is provided, clarifying what happened and why certain decisions were made. This helps participants understand the context and avoid misunderstandings.

3. Operational Discussion: The team discusses the operational aspects, identifying what was done well and what could be improved. This is critical for learning and improving future responses.

4. Emotional and Psychological Impact: Participants share their emotional reactions, providing a space for acknowledging the psychological effects of the event. This aspect of debriefing is vital for team support and individual well-being.

5. Closing and Follow-Up: The debrief concludes with a summary and any agreed-upon actions. Facilitators also provide information on additional support resources, if necessary.

Challenges and Considerations

Debriefing can be challenging, especially in navigating sensitive topics or when there are conflicting opinions. It's essential to create a safe space where all participants feel comfortable sharing. Facilitators must manage the discussion to ensure that dominant personalities do not overshadow quieter voices, encouraging everyone to contribute.

In some cases, separate debriefs for different groups involved in the event—such as pre-hospital staff, nurses, and doctors—may be necessary. This approach ensures that discussions are relevant to each group's experiences and prevents unnecessary exposure to distressing details that may not be directly applicable.

Broader Implications and Benefits

Debriefing should not be limited to negative or critical incidents. Regularly debriefing both positive and challenging events fosters a culture of continuous improvement and support. It helps normalize the practice, making it an integral part of the workplace rather than an extraordinary event.

It's important to recognize that not all staff may want to participate in debriefings, and that’s acceptable. Debriefing should always be voluntary, with alternative support mechanisms available for those who need them.

The long-term benefits of debriefing are substantial. It helps prevent burnout by providing a space for staff to process their experiences, supports continuous learning, and improves patient care outcomes. A well-implemented debriefing process can enhance team cohesion, reduce staff turnover, and foster a positive workplace culture.

Conclusion

Debriefing is a vital component of healthcare practice in emergency and critical care settings. It provides a structured approach to reflect on critical events, offering both operational and psychological support to healthcare teams. While it requires time and effort, the benefits for staff well-being and patient care are invaluable.

We encourage healthcare professionals to integrate regular debriefing into their practices, not just for critical incidents but as a routine part of their work. This approach helps build a resilient and supportive workplace culture, where staff feel valued and heard. Sharing experiences and learning from each other strengthens the team and ultimately leads to better care for patients.

We invite you to share your experiences with debriefing in your hospital. What strategies have worked well? What challenges have you encountered? Connect with us through the St. Emlyn's blog or Twitter, and let's continue the conversation about improving our practices and supporting each other in this challenging yet rewarding field of healthcare. Stay tuned for more insights from St. Emlyn's as we explore the complexities of working in emergency and critical care. Until next time, take care and keep supporting each other.

 

 

 

Ep 105 - Critical Apprasal Nugget 8: Diagnostics and PICTR questions.

Understanding Diagnostic Test Accuracy Studies in Emergency Medicine

In the St Emlyn's podcast, hosts Simon Carley and Rick Bodey explore the crucial aspects of diagnostic test accuracy studies, particularly relevant for emergency medicine. This discussion revolves around the PICTR framework, a tool for structuring research questions and critical appraisals in diagnostic studies. PICTR stands for Patient group, Index test, Comparator, Target condition, and Reference standard.

Patient Group: Contextual Relevance in Diagnostics

The patient group is the specific population in which the diagnostic test is evaluated. It's essential to select a relevant group to ensure the study's findings are applicable to real-world settings. For example, a cardiac marker tested in a specialized cardiology clinic may not perform identically in the diverse environment of an emergency department. In practice, the patient group should include all individuals who present with symptoms indicative of the condition the test aims to diagnose, providing a broad and pragmatic study population.

Index Test: The New Diagnostic Tool

The index test is the new diagnostic tool being evaluated. Key factors include how and when the test is applied, the conditions under which it is used, and the training of the clinicians administering it. For example, if evaluating a new troponin test, the timing of sample collection and the level of operator training are crucial, as these can significantly influence the test's accuracy and reliability. Understanding these details ensures that the study results can be replicated in different clinical settings and with various levels of clinician expertise.

Comparator: Benchmarking Against Existing Tests

The comparator is an existing diagnostic test or standard used to measure the new test's effectiveness. This comparison helps determine whether the new test offers improvements over current practices. For instance, when comparing a new scoring system for assessing chest pain against the TIMI risk score, researchers can evaluate which method more accurately identifies patients at risk for acute coronary syndromes. However, not all studies include a comparator, especially if the new test is intended to replace an existing standard entirely.

Target Condition: Defining the Diagnosis

The target condition refers to the specific illness or condition that the test aims to diagnose. Defining this condition involves setting clinical criteria or thresholds. For example, the criteria for diagnosing myocardial infarction have evolved with advancements in biomarker sensitivity, such as the use of high-sensitivity troponins. A meaningful target condition is one that impacts clinical decision-making and patient management, ensuring that the diagnosis leads to actionable insights that improve patient outcomes.

Reference Standard: The Benchmark for Accuracy

The reference standard, often called the "gold standard," is the most accurate method available for confirming whether a patient has the target condition. It serves as the benchmark against which the new diagnostic test is measured. However, reference standards can have limitations, such as false negatives or positives. For example, while a CT pulmonary angiogram (CTPA) is a common reference standard for diagnosing pulmonary embolism, it is not perfect. In some cases, a new test may outperform the reference standard, highlighting the need for careful interpretation of study results.

Challenges with Reference Standards

Applying the reference standard uniformly across all patients can be challenging, especially when the standard is invasive or carries risks. For example, diagnosing subarachnoid hemorrhage typically involves a CT scan followed by a lumbar puncture. However, not all patients may undergo these procedures due to their invasive nature. In such cases, researchers may use follow-up data as a proxy, assuming that if no adverse outcomes occur during the follow-up period, the patient likely did not have the target condition.

This approach helps mitigate the ethical concerns and practical challenges associated with applying invasive reference standards to all study participants. It also highlights the importance of being pragmatic when appraising diagnostic studies, focusing on the clinical relevance and applicability of the findings rather than striving for methodological perfection.

Practical Considerations in Diagnostic Studies

Critical appraisal of diagnostic studies involves evaluating the study's design, including the selection of the patient group, the application of the index test, and the choice of the reference standard. Researchers and clinicians must also consider the study's limitations, such as potential biases or the imperfect nature of the reference standard. These factors can affect the study's conclusions and their relevance to clinical practice.

Understanding and applying the PICTR framework helps ensure that diagnostic studies are comprehensive and provide valuable insights for clinical decision-making. It allows for better evaluation of new diagnostic tools, ensuring they are safe, effective, and applicable in real-world clinical settings.

Conclusion: The Value of PICTR in Diagnostic Research

The PICTR framework provides a structured approach to designing and evaluating diagnostic test accuracy studies. By focusing on patient groups, index tests, comparators, target conditions, and reference standards, researchers can produce more accurate and clinically useful results. This approach is crucial in emergency medicine, where timely and accurate diagnoses can significantly impact patient outcomes.

For clinicians, mastering the principles of PICTR enhances the ability to critically appraise research and make informed decisions about the implementation of new diagnostic tests. As diagnostic technologies continue to evolve, the importance of robust, evidence-based assessments will only grow, ensuring high-quality patient care and optimal use of healthcare resources.