The St.Emlyn’s Podcast

Ep 6 - SMACC Back-Back on What to believe and when to change.

Navigating the Challenges of Early and Late Adoption in Medical Practice

In the ever-evolving landscape of medicine, the timing of adopting new treatments and technologies is a critical decision for clinicians. Simon Carley, in a discussion with Scott from St. Emlyn's podcast, delves into the complexities of being an early or late adopter, exploring the associated risks and benefits. This conversation highlights the fine line between innovation and patient safety, and the careful considerations required for responsible clinical practice.

The Risks of Early and Late Adoption

Both early and late adoption come with inherent dangers. Early adopters, eager to implement new innovations, may face unforeseen consequences. A historical example is the use of flecainide in the 1980s, initially believed to reduce ventricular disruptions in post-MI patients. However, it was later found to potentially cause more harm than benefit, underscoring the unpredictability of medical advances. On the other hand, late adopters risk failing to provide patients with the latest and most effective treatments, potentially resulting in suboptimal care.

Carley emphasizes the importance of a balanced approach, avoiding the pitfalls of both extremes. He discusses the concept of "dogmalacis," the enthusiasm for challenging established medical practices with new evidence. Both he and Scott agree that while it is essential to embrace new findings, clinicians must do so with caution and a thorough understanding of the current evidence base.

The Complexity of Determining Optimal Timing

Determining the optimal timing for adopting new practices—referred to as the "Goldilocks moment"—is complex and often only clear in hindsight. Carley notes that senior clinicians, in particular, must exercise careful judgment, understanding the strength of the evidence supporting current practices before making changes. This prudence is crucial to ensure that new practices are adopted based on solid evidence rather than mere enthusiasm.

Case Study: Targeted Temperature Management (TTM) Trial

The discussion includes a specific example: the Targeted Temperature Management (TTM) trial, which challenged previous beliefs about the benefits of hypothermia in post-cardiac arrest care. The trial suggested that fever avoidance was more critical than aggressive cooling, sparking significant debate. This case illustrates how new evidence can disrupt established practices and provoke emotional responses among practitioners.

Carley and Scott also discuss the need for rigorous evidence, particularly randomized controlled trials (RCTs), to support the adoption of new technologies and treatments. They highlight the glidescope trial, which demonstrated potential harm from the device in a randomized setting. The scarcity of such trials in evaluating new medical technologies points to a gap in evidence-based practice, stressing the importance of high-quality research to guide clinical decisions.

Balancing Innovation with Caution

Carley shares personal reflections on the challenges of balancing innovation with caution. While acknowledging the necessity of early adopters for medical progress, he stresses the need for careful consideration and expertise. Not every clinician or situation is suited for early adoption; it requires a deep understanding of the underlying science and a cautious approach to patient care.

He draws parallels between professional and personal experiences, noting his own tendency toward late adoption in certain areas, such as his decision to marry. This anecdote serves as a metaphor for the broader discussion, highlighting that timing in adoption is crucial and often a personal, context-dependent decision.

Embracing Continuous Improvement

The conversation culminates in a shared commitment to continuous improvement in medical practice. Both Carley and Scott emphasize the importance of doing the best with current knowledge and being ready to change when better evidence becomes available. They resonate with Maya Angelou's quote: "Do the best you can until you know better. Then when you know better, do better." This principle captures the essence of their discussion, advocating for a flexible and reflective approach to clinical practice.

Conclusion

Navigating the challenges of early and late adoption in medicine requires a careful balance between innovation and caution. Clinicians must be willing to embrace new evidence and change practices while ensuring that these changes are grounded in solid, high-quality research. The dialogue between Simon Carley and Scott highlights the complexities and responsibilities involved in this process, underscoring the need for continuous learning and adaptability in medical practice. Through thoughtful consideration and a commitment to evidence-based care, clinicians can optimize patient outcomes and advance the field of medicine.

Ep 5 - Understanding diagnostics in Emergency Medicine Part 3 - Prevalance

Exploring Diagnostic Testing in Emergency Medicine: A St Emlyn’s Perspective

Welcome back to the St Emlyn’s podcast! Today, we're diving deep into the world of diagnostic testing in emergency medicine, inspired by a recent discussion featuring our esteemed colleague Rick Boddie. This episode sheds light on the complexities of diagnosis, the probabilities involved, and the importance of shared decision-making with patients.

Understanding Diagnostic Probabilities

One of the critical points raised by Rick is the significance of understanding diagnostic probabilities. For instance, if a population has a 10% prevalence of a condition and we use a test with 90% sensitivity and 70% specificity, the post-test probability can be less than 2%. This scenario prompts the question: should we discharge a patient based on this probability or admit them for further testing?

In emergency medicine, our goal is to identify patients with serious conditions efficiently. Consider a thousand patients with chest pain; if the prevalence is 10%, around 100 of them will have the disease. With a 98% sensitivity test, we'll identify 98 patients but potentially miss two. However, this translates to missing only one in 500 patients overall, which is relatively low but still significant when considering the potential consequences of a missed diagnosis.

Consequences of Missed Diagnoses

The consequences of a missed diagnosis can vary. For some conditions, missing a diagnosis might not lead to severe outcomes. For instance, a small subarachnoid bleed might never recur, or an early-stage appendicitis could resolve on its own. In such cases, there might be no adverse consequences, and the patient could even benefit by avoiding unnecessary treatments.

However, for conditions like myocardial infarction (MI), the stakes are higher. Missing an MI can lead to severe complications, including cardiac arrest. Yet, it’s crucial to recognize that not every missed MI will result in a catastrophic outcome. Often, patients with missed diagnoses will experience further symptoms, allowing them another opportunity to seek medical attention.

Balancing Diagnostic Accuracy and Over-Investigation

In emergency medicine, we constantly balance the need for diagnostic accuracy with the risks of over-investigation. Over-investigating can lead to false positives, unnecessary treatments, and additional harm to patients. Therefore, it’s essential to adopt evidence-based guidelines and principles that help us make informed decisions without overburdening the diagnostic process.

One approach to achieving this balance is through shared decision-making with patients. Engaging patients in discussions about the risks, benefits, and potential harms of diagnostic tests can lead to better outcomes and increased patient satisfaction.

Shared Decision-Making in Practice

Shared decision-making is particularly valuable in complex cases, such as evaluating pregnant women for pulmonary embolism (PE). In these situations, the standard diagnostic pathway might involve tests that expose the patient and fetus to ionizing radiation. By discussing alternative diagnostic interventions, such as leg ultrasounds or modified VQ scans, we can involve patients in the decision-making process and tailor the diagnostic approach to their specific needs and concerns.

The Legal and Institutional Perspective

From a legal and institutional perspective, adhering to established guidelines and evidence-based practices provides protection for clinicians. If a missed diagnosis occurs despite following these principles, it is considered an acceptable risk within the diagnostic process. This understanding helps mitigate the fear of legal repercussions and allows clinicians to focus on delivering the best possible care based on current evidence.

Communicating with Patients

Effective communication with patients is a cornerstone of good medical practice. Instead of giving definitive statements like "you do not have this condition," it's more helpful to say, "we haven't found anything serious this time, but if you have any further symptoms or concerns, please come back." This approach not only sets realistic expectations but also encourages patients to seek further care if needed without feeling dismissed.

The Role of Technology in Diagnostics

Looking to the future, advancements in diagnostic technology could revolutionize emergency medicine. Imagine having a tool that could predict a patient's 30-day outcome or a "painometer" to measure pain levels accurately. Such innovations would enhance our ability to make precise diagnoses and provide targeted treatments, ultimately improving patient care.

Conclusion

Diagnostic testing in emergency medicine is a complex, nuanced process that requires balancing probabilities, understanding the consequences of missed diagnoses, and engaging in shared decision-making with patients. By adhering to evidence-based guidelines and maintaining open communication with patients, we can navigate these challenges effectively and deliver high-quality care.

At St Emlyn’s, we continuously strive to improve our diagnostic approaches and encourage open discussions about these critical topics. We invite you to share your thoughts and experiences with us on our website or via Twitter. Together, we can enhance our understanding and practices in emergency medicine.

Stay tuned for more insights and discussions in our next podcast episode. Until then, keep exploring, learning, and advancing the field of emergency medicine.

More listening about diagnosis

Podcast – Diagnosis in Emergency Medicine Part 1 – SpIN and SnOUT

Podcast – Diagnosis in Emergency Medicine Part 2 – Beyond a simple yes or no

Podcast – Diagnosis in Emergency Medicine Part 3 – The importance of prevalence

 

Ep 4 - Understanding diagnostics In Emergency Medicine Part 2 - Beyond Yes or No

What is a Diagnosis?

A diagnosis is essentially a label that we put on a patient to indicate what they have, which then guides our treatment decisions. In the ED, our primary focus is on identifying life-threatening conditions. This approach often involves working backwards by first ruling out serious conditions before considering what a patient might actually have.

Initial Diagnostic Approach

As emergency physicians, our initial approach is to use tests with high sensitivity. These tests are designed to pick up anyone who might have the disease. Once we rule out the serious conditions, we look at tests with high specificity to confirm the diagnosis, as treatments often carry risks. For example, therapies such as thrombolysis come with significant risks, so we need to be fairly certain before proceeding, unlike less consequential treatments like wrist splints.

Understanding Probabilities in Diagnoses

When we say a patient has a diagnosis, we’re essentially saying it’s likely enough to treat. Conversely, when we say a patient doesn’t have a diagnosis, we mean it’s unlikely enough to withhold treatment. This probabilistic approach is vital in the ED and can be surprising to many people.

Case Study: Cardiac Chest Pain

Let’s apply this to a patient with cardiac-sounding chest pain. Our goal is to either rule out or confirm the disease and start appropriate treatment. We start with specific tests to rule in a diagnosis, such as an ECG. A positive ECG with significant ST segment changes indicates a high likelihood of disease, warranting immediate treatment. This approach quickly sorts out high-risk patients.

For patients with normal or near-normal ECGs but still concerning symptoms, we need sensitive tests to ensure we don't miss anyone with myocardial disease. About 10% of these patients might have underlying issues, so we need to ensure our tests are sensitive enough to catch these cases.

Using Prevalence and Pre-test Probability

To decide if a patient has the disease, we must consider the prevalence or pre-test probability in our population. For example, in patients with normal ECGs and no alarming history, the pre-test probability might be around 10%. This isn’t low enough to rule out the disease but also not high enough to justify treatment without further testing.

Diagnostic Processes in the ED

We use a step-by-step diagnostic process. Starting with the most specific tests to rule in a diagnosis, we then use sensitive tests like high-sensitivity troponin to rule out diseases. High-sensitivity troponin tests are great for ruling out diseases due to their sensitivity. If the test is negative, we can be confident the patient doesn’t have myocardial damage. If the test is positive but not dramatically high, we may need additional tests to confirm the diagnosis.

Each diagnostic step adjusts our patient’s probability of having the disease. Our goal is to reach a probability low enough to safely rule out the disease or high enough to justify treatment. This process is continuous, and we apply it to every patient, whether they have chest pain or another symptom like a headache.

Understanding Likelihood Ratios

We often use likelihood ratios to interpret diagnostic tests. A positive likelihood ratio increases the probability of the disease, while a negative likelihood ratio decreases it. For example, a high-sensitivity troponin test is excellent at ruling out myocardial infarction because of its high sensitivity, though it’s not as good at ruling in due to lower specificity.

Optimising Diagnostic Tests

Diagnostic tests like troponin can be optimized by adjusting the threshold levels. For instance, a higher threshold might improve specificity and thus be better at ruling in the disease, while a lower threshold improves sensitivity, making it better at ruling out the disease. This principle applies to various tests, including white cell counts and amylase levels.

Continuous Assessment and Reassessment

In the ED, we continuously assess and reassess patients. Each diagnostic step, whether it’s asking a question about symptoms or ordering a lab test, adjusts our understanding of the patient’s condition. This iterative process helps us make informed decisions about treatment and ensures that we don’t miss critical diagnoses.

Applying the Approach to Different Symptoms

This diagnostic approach isn’t limited to chest pain. Whether a patient presents with a headache, abdominal pain, or any other symptom, we apply the same principles of sensitivity, specificity, and likelihood ratios. Each question we ask and each test we perform helps refine our assessment and move closer to a definitive diagnosis.

Conclusion

Mastering diagnostic skills in the ED involves understanding and applying probabilities, using specific and sensitive tests effectively, and continuously reassessing the patient’s condition. By focusing on these principles, we can make more accurate diagnoses, provide appropriate treatments, and ultimately improve patient outcomes.

More listening about diagnosis

Podcast – Diagnosis in Emergency Medicine Part 1 – SpIN and SnOUT

Podcast – Diagnosis in Emergency Medicine Part 2 – Beyond a simple yes or no

Podcast – Diagnosis in Emergency Medicine Part 3 – The importance of prevalence

Ep 3 - Understanding diagnostics In Emergency Medicine Part 1. SNout SpIn and Probability

Patients often come to us with the fundamental question: "Doctor, what's wrong with me?" Our goal is to provide an answer through history, examination, and tests. Let's explore what it means to make a diagnosis in emergency medicine.

The Role of Diagnosis in Emergency Medicine

In day-to-day practice, making a diagnosis often means applying a label to a patient. This label helps us decide on the next steps, whether to treat or reassure and send them home. In emergency medicine, we frequently focus on ruling out serious conditions rather than confirming them. This approach allows us to prioritize immediate life-threatening issues and manage resources effectively.

Working Backwards: Ruling Out Serious Conditions

Our primary concern in emergency medicine is to identify conditions that can kill quickly, often within hours. Therefore, we start by ruling out the most serious conditions first. Diagnostic tests, including history and physical examination, play a crucial role in this process. Every question we ask and every examination we perform are part of our diagnostic strategy, aiming to rule out or confirm serious illnesses.

Sensitivity and Specificity in Diagnostic Testing

Understanding diagnostic tests involves two key concepts: sensitivity and specificity.

• Sensitivity refers to a test's ability to correctly identify those with the disease (true positives). High sensitivity means that a negative test result is reliable for ruling out the disease.
• Specificity measures a test's ability to correctly identify those without the disease (true negatives). High specificity means that a positive test result is reliable for confirming the disease.

For example, a D-Dimer test for thrombotic disease is highly sensitive. It picks up most cases of the disease but also includes some false positives. Conversely, a highly specific test like jaw claudication for temporal arteritis has very few false positives but isn't useful as a broad screening tool because only a small percentage of patients with the disease exhibit this symptom.

The Importance of Probability and Risk

In emergency medicine, we rarely achieve 100% certainty in diagnosis. Tests with 98% sensitivity, for instance, still miss 2% of cases. This level of uncertainty is part of our practice, and we must communicate it effectively to patients. Explaining the probabilistic nature of diagnosis helps patients understand the limitations of medical testing and the importance of follow-up if symptoms persist or worsen.

Balancing Diagnosis and Treatment

The consequences of diagnosing and treating a condition vary. For life-threatening conditions like myocardial infarction (MI), the treatment involves significant interventions such as thrombolysis or PCI, which carry their own risks. Therefore, we need a high degree of certainty before initiating such treatments. In contrast, diagnosing a viral sore throat, which requires minimal intervention, demands less certainty.

Continuous Learning and Improvement

Reflecting on our diagnostic processes is crucial for improvement. Recognizing that we work in a probabilistic environment helps us balance the need for thorough investigation with the risk of over-testing. By continuously learning and refining our approach, we can enhance patient care and outcomes.

Favourite Diagnostic Tools

To conclude, let's talk about our favorite diagnostic tools. Personally, I appreciate the value of ultrasound in the resuscitation room, especially for diagnosing pneumothorax in trauma patients. It's a quick, effective tool that guides immediate intervention. Simon, on the other hand, highlights the D-Dimer test. Despite its controversial reputation, it serves as a prime example of a test that, when understood and used correctly, can be incredibly valuable.

We hope this podcast has provided some insight into the complexities and nuances of diagnosis in emergency medicine. Stay tuned for our next episode, where we'll delve deeper into the probabilistic nature of diagnosis and how we make informed decisions in the emergency department. Until then, take care and continue to enjoy your practice in emergency medicine.

More listening about diagnosis

Podcast – Diagnosis in Emergency Medicine Part 1 – SpIN and SnOUT

Podcast – Diagnosis in Emergency Medicine Part 2 – Beyond a simple yes or no

Podcast – Diagnosis in Emergency Medicine Part 3 – The importance of prevalence

Ep 2 - SMACC Chicago

St. Emlyns Podcast: Get Ready for SMACC Chicago

Welcome to the St. Emlyns podcast! I'm Simon Carly, and with me is Ian Beetzel. We are emergency physicians from the UK, deeply involved with the St. Emlyns team. After years of bringing you insightful content through our blog, we’ve now ventured into podcasting. Today, we’re excited to talk about the upcoming SMACC Chicago conference.

What Makes SMACC Chicago Special?

SMACC (Social Media and Critical Care) conferences are renowned for their exceptional blend of academic excellence and engaging presentation styles. These events are meticulously organized by Roger Harris, Oli Flower, and Chris Nixon, who have a track record of creating unforgettable experiences.

Key Highlights:

• Innovative Format: Unlike typical conferences, SMACC sessions are designed to be performances that make learning enjoyable. It’s like attending a theatre production that educates you at the same time.
• Top-Notch Speakers: The conference attracts world-class speakers who are leaders in their fields, ensuring you gain the latest insights and practical knowledge.
• Engaging Content: From rigorous scientific discussions to thought-provoking talks on how we think and feel, SMACC covers a broad spectrum of topics in an engaging manner.

Building Anticipation for SMACC Chicago

The excitement for SMACC Chicago is building rapidly. On social media platforms like Twitter, the buzz is palpable. Professionals are planning their study leave a year in advance, highlighting the significance and allure of this event. Such anticipation underscores the conference's reputation and the high expectations attendees have.

Importance of UK Representation

We believe it's crucial for UK emergency medicine professionals to be well-represented at SMACC Chicago. Despite some recent negative press, UK emergency medicine is pioneering, and showcasing this on an international stage is vital. We urge UK doctors, nurses, paramedics, and other emergency medicine professionals to join us in Chicago to demonstrate our strengths and innovations.

Why You Should Attend SMACC

Attending SMACC is not just about professional obligation; it’s a transformative experience. Here’s why you should consider joining us:

1. Professional Growth: The conference offers a unique mix of academic rigor and practical knowledge. You'll return as a better clinician with the latest insights and techniques.
2. Networking Opportunities: Connect with peers and experts from around the globe. The diverse group of attendees provides a rich environment for sharing experiences and building professional relationships.
3. Inspiration and Motivation: The energy at SMACC is infectious. You'll leave inspired and motivated to implement new ideas and improve patient care.

Reflecting on Past SMACC Conferences

The previous SMACC conferences in Sydney and the Gold Coast set high standards:

• Sydney and Gold Coast Highlights: These conferences successfully blended social media engagement with academic learning. They featured both right-brain talks that explored cognitive and emotional aspects, and left-brain talks focused on scientific data and clinical practices.
• Interaction with Leading Researchers: Participants had opportunities to engage with top researchers like Steve Bernard, who discussed groundbreaking work and its implications for clinical practice.

Looking Forward to SMACC Chicago

The lineup for SMACC Chicago promises to be incredible, featuring:

• Cutting-Edge Resuscitation Techniques: Sessions will cover the latest advancements in resuscitation, looking ahead 10-15 years.
• Right-Brain Thinking Sessions: These will challenge attendees to think differently and become more holistic clinicians, regardless of their background—nursing, intensive care, paramedicine, or emergency medicine.
• Academic Rigor: High-quality academic content will be abundant, providing a wealth of knowledge to apply in your practice.

Practical Information: Plan Your Trip

Now is the time to start planning your trip to SMACC Chicago. Here are some tips:

1. Book Study Leave Early: Given the excitement and demand, securing your study leave well in advance is crucial.
2. Arrange Travel and Accommodation: Chicago is an amazing city with much to offer. Book your flights and accommodation early to get the best deals.
3. Engage on Social Media: Stay updated with the latest news and announcements related to SMACC Chicago by following the conversation on Twitter and other platforms.

Conclusion: Join Us at SMACC Chicago

In summary, SMACC Chicago promises to be an unparalleled event in the world of emergency medicine. With its unique blend of academic excellence, engaging presentations, and networking opportunities, it’s an experience you won’t want to miss.

We urge UK emergency medicine professionals to join us in Chicago. Your presence will not only enhance your professional development but also showcase the strength and innovation of UK emergency medicine on an international stage.

Book your study leave, arrange your travel, and prepare for an unforgettable experience at SMACC Chicago. We look forward to seeing you there!

Keywords: SMACC Chicago, St. Emlyns, emergency medicine conference, UK emergency medicine, professional development, medical conference 2024, resuscitation techniques, medical networking, medical education, emergency physicians, nursing, paramedics, intensive care.

Tags: SMACC, St. Emlyns, emergency medicine, medical conference, professional growth, networking, medical education, Chicago 2024.

Authors: Simon Carly and Ian Beetzel

Stay tuned for more updates on the St. Emlyns podcast and blog. Follow us on Twitter for the latest news and insights in emergency medicine.

Ep 1 - St.Emlyn's The Podcast - An Introduction

Welcome to the St Emlyn's Podcast: A New Chapter in FOAMed

We're thrilled to announce the launch of the St Emlyn's podcast, bringing fresh perspectives and insights from the world of emergency medicine. I'm Iain Beardsell, and alongside Simon Carley, we're excited to extend our reach from the St Emlyn's blog to your favourite podcast platforms.

Why a Podcast?

The landscape of medical education is evolving, and while there's a plethora of excellent podcasts out there, there's a notable gap in UK-centric content. Our aim is to fill that void, offering a unique blend of clinical discussions, evidence-based medicine, and practical management tips tailored for emergency physicians in the UK and beyond.

What is FOAMed?

For those new to the term, FOAMed stands for Free Open Access Medical Education. It's a philosophy we deeply believe in: sharing knowledge, experiences, and lessons to improve patient care globally. FOAMed isn't just about free resources; it's about fostering a community where we can all learn from each other.

What Makes St Emlyn's Podcast Unique?

While we draw inspiration from giants like EMCrit and Scott Weingart, our podcast will provide a distinct UK perspective. Here's what you can expect:

1. Evidence-Based Medicine: We'll dive deep into journal appraisals and discuss the latest research, making it relevant to our everyday clinical practice.
2. Practical Clinical Tips: As practising clinicians, we bring real-world experience from our busy emergency departments, tackling the challenges we all face.
3. Management Insights: Working in high-intensity, high-risk environments, we’ll share strategies on managing departmental flow, dealing with access block, and improving patient outcomes.

Upcoming Episodes

Our first few episodes will focus on diagnosis—a cornerstone of emergency medicine. We'll explore what makes diagnostic tests effective, how to interpret them, and why sometimes we just get lucky. Understanding these elements is crucial for any emergency physician aiming to excel in their field.

Join Our Journey

We’re not just podcasters; we're part of a broader community of emergency medicine professionals. We'll be featuring guests who are experts in their fields, sharing their insights and experiences. These aren't just any guests; they're some of the smartest and most renowned clinicians, who, unbeknownst to them, will soon be part of our podcasting journey.

A Regular Dose of Education

We plan to release episodes regularly, ensuring you have a steady stream of content to enhance your practice. Whether you're commuting, walking the dog, or just relaxing, our podcast will be a valuable addition to your routine.

Stay Tuned

Subscribe to our podcast on iTunes or your preferred platform, and keep an eye on the St Emlyn's blog for more updates. We look forward to embarking on this new journey with you, bringing the best of emergency medicine education to your ears.

Thank you for joining us, and let's make this an engaging and enlightening experience for all.

 

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