The St.Emlyn's Podcast

Welcome to the St.Emlyn's podcast. After a few years messing around with the blog at stemlynsblog.org the Choirmaster at St.Emlyn's has decided that some audio contributions are necessary. We will therefore be relaunching the podcast in a uniquely British way.

The St.Emlyn's choirmaster has asked Iain and Simon to deliver a sermon on the importance of attending the SMACC Chicago conference in May 2015. After their pilgrimages to Australia in 2013 and 2014 they came back enthused and at times rather annoying about how jolly marvellous it all was. 

A podcast discussing sensitivity and specificity of diagnostic tests and how we can use this in our everyday medical care of patients. 

This article from the Centre for Evidence Based Medicine is also useful. 

Dear all,

Iain and Simon tackle the effect of prevalence on diagnostic performance. Mrs Trellis of North Wales makes a return appearance to discuss the delicate issues of sensitivity and Rick Body joins us by mail to raise concerns about the difficulties of missing patients with myocardial disease.

Listen and enjoy, visit the blog site and keep in touch.

Don't forget to subscribe to the podcast via iTunes, to subscribe to the blog site and to like us on facebook.

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Hopefully you will have already seen and listened to my SMACC talk on 'What to believe and when to change'. If not then please whizz over to the site now and have a listen. I really enjoyed exploring the uncertainties that exist around when we decide to adopt or abandon therapies.

My belief is that it's really difficult to define the perfect moment and that it's only in retrospect that we can define it.

Since appearing on the ICN network and St.Emlyn's, Scott Weingart, one of the best and most innovative clinicians I know has come back and argued for early adoption. You can check out his rationale on his site and see what you think.

I actually agree with many of the things he tells us, although he has confined himself to one side of the argument. In terms of a defence of early adoption he makes a good case, but like all debates there needs to be another side to the story, so sit back and listen to why we must reflect hard on the decisions we make in deciding what we do, why we do it, and most importantly when.

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Iain and Simon chat about how we can start to translate research findings in to natural frequency summaries that help clinicians and patients alike understand the value of therapeutic interventions.

The NNT site we mention is just fantastic. Visit them here 

Great revision page here by the amazing LITFL crew 

The NNT for tranexamic acid is 67 not 50.

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Iain and Simon discuss the challenges of getting our trauma patients to the CT scanner within 30 minutes of arrival.

The 30 minute target is a UK standard, and we did not set it! All UK trauma centres are judged against the target and (rightly or wrongly) it has become a real issue for many centres.

We would be really be interested in what our International colleagues think about the target and the resultant strategies outlined by the team. There's more on this at the St.Emlyn's website.

As always, we'd love to hear your comments.

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It is a little known fact that to be successful as an emergency physician in the UK it is vital to take a three month rotation in Archery. Archery is a key skill for us all dating back to Medieval times when we introduced the longbow into warfare. This devastating tool could cause panic in opposing forces, scattering them into many wide and ineffective directions. In short they were an effective tool to cause and disruption inthe opposition ranks whilst the noble English armies of old strode forward with their visions of the future. Soldiers trained using targets to hone their skills and to focus on the aim - meeting the target.

Of course these days we do not have real bows and arrows in the emergency department, but archery remains alive and well. In the modern NHS we still train our troops in archery, or at least in the principle aim of archery - to meet the target.

With our long history of target setting and target hitting it is therefore no suprise that we are world leaders in standards/targets/indicators....., whichever term you prefer in fact and it has to be said that a target culture in the NHS has been criticised widely, even being blamed for the exodus of trainees to Southern climes, but there is arguably more to it than that.

In last weeks episode we touched on new targets around trauma care in the UK and that raised many questions and opened a debate on twitter. This week we want to take those thoughts further and ask what we, as the archiest of arch archers across the entire NHS can do with these externally set targets.

What we forgot to say in the podcast is the absolute need to work alongside a short stay admissions unit under the ED umbrella. Without that you would really struggle to deliver safe and efficient care. We both work in units with short stay admission units that allow us to deliver safe diagnostic and therapeutic interventions to our patients.

So, with some trepidation Iain and I ask whether all targets are a bad thing....

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If you're starting out in EM then it can be a scary time. Iain and Simon talk through some of the initial anxieties and ask what you need to know to be safe, sensible and super.

Do you remember when it took three days to 'rule in' or 'rule out' an acute myocardial infarction (AMI)?  When I was a medical student doing my first clinical attachments, I remember doing ward rounds on the CCU seeing patients with suspected AMI.  The way they were managed is a million miles from what we do now.  Back then, patients would have serial ECGs and then be admitted for cardiac enzyme evaluation over the course of the next 3 days.  We'd measure CK, AST and LDH.  'CK' was the so-called 'early marker', which would rise early after the start of an AMI.  Today we use CK as a marker of skeletal muscle damage (e.g. rhabdomyolysis).  AST and LDH (today we think of these as liver function tests, I know) were the 'late markers' - and by late I really mean late - we might see a rise on days 2 and 3.

Could you imagine for a second, in today's world, ruling out AMI because their CK and LFTs were normal?  It's completely unthinkable.  That's how much cardiac troponin has changed our practice.  We rely on it so completely to diagnose AMI.  And yet, it's one of the most misunderstood tests in medicine.  Given how much we use it, I guess we feel that we all should know lots about this test.  But doctors still have so many questions.  Here are just a few:

• What is cardiac troponin?
• Why is it a marker of AMI?
• What else causes a raised troponin and how?
• Should we be doing troponins at 3 hours, 6 hours, 12 hours?  What's the difference and what's the evidence?
• What is a 'delta troponin'?
• What do you need to 'rule in' AMI?
• How do you use cardiac troponin in patients with renal failure?

This is just a brief list.  With the research I do in this area and my experience developing protocols/guidelines, people get in touch to ask questions like this quite a lot.  There are loads of questions that people ask - but there are lots of themes in common.  We thought it was about time we produced a handy run down in the true spirit of #FOAMed.

Take a listen to Part 1 of our troponin podcast.  While Simon and Iain have been prolifically churning out spectacular stuff for some time now, this is my debut on the St. Emlyn's podcast.  I really enjoyed talking about troponin with Iain - and I hope we covered some useful stuff.

We'll cover more in part 2, when we'll move on to discussing high sensitivity troponins, what they are, how to use them and how to speak the troponin lingo.  Please get in touch if there's anything we haven't covered that you'd like us to, or if there's anything you'd like us to elaborate on some more!

Rick

We've all had headaches, but not often severe enough to prompt us to seek help in an Emergency Department.

In our practice 10% of patients who do present to the ED  with a primary presentation of headache will have serious pathology and our job as Emergency Physicians is to work out who these are. Key to this is actively ruling out the life-threatening and life-changing diagnoses:

• Subarachnoid Haemorrhage
• Meningitis
• Tumours and Space Occupying Lesions
• Temporal Arteritis

Listen to Simon and Iain discuss how to approach these patients here

Further Resources

Headaches at Life in the Fast Lane - a great summary from the LiTFL crew

NICE Guidelines (NCG150) - diagnosis and management of headaches; there's a flowchart and some red flags although you could read the St Emlyn's summary here!

Headache from the Flipped EM Classroom

Breathless patients are a challenge in the ED. Shortness of breath can be a frightening presenting complaint for both patients and doctors. As always, think about the possible life threatening causes and actively rule them out. For breathless patients think especially about:

• Pneumonia
• Asthma/COPD
• Pulmonary Embolism
• Acute left ventricular failure
• Pneumothorax

Breathless Patients Podcast

In this podcast Iain and Simon discuss their approach to breathless patients in the ED which we hope will provide you with a good starting point.

 For those of you who are more visual learners here is the video recorded a few years ago for SEMEP featuring our very own Iain Beardsell.

http://vimeo.com/35310564

Take Home Points

Recently we published part one of our series on cardiac troponins.  If you haven't checked it out yet, you can find it here.    In the second part, we're going to take a look at high sensitivity troponins and some of the more advanced areas around understanding cardiac troponin and its use in practice.  We'll give you a quick run down on the troponin lingo - the language you need to be able to speak in order to fully understand how to use high sensitivity troponin in your practice, including terms like the limit of blank, limit of detection, co-efficient of variation and 99th percentile.

We'll also ask whether Joe Lex had a point when he stirred up controversy around these assays with this legendary tweet:

What if we called it "low specificity troponin" instead of "high sensitivity troponin?" Would that knock some sense into people?

— Joe Lex (@JoeLex5) October 9, 2012

So, check out the associated BLOG POST here and listen to the podcast. There is more on diagnostics and troponin to come very soon.

Hope you enjoy! Please keep the feedback, questions and comments coming. As always, we'd love to hear from you.

Rick

DOI: Much of my research work involves HsT. To help with this I have received reagents from companies who make HsT assays, but I not received any other financial benefit or gifts in kind as part of my work and have no financial ties to any companies.

This podcast is part of our induction series for new docs starting in UK emergency departments.

You can check out the full post and supporting materials over at the main St.Emlyn's website.

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John Hell is a Neurointensivist at University Hospital Southampton and very kindly gave up an afternoon to record his thoughts and share his considerable wisdom about Diffuse Axonal Injury.

I also managed to get him to discuss some other topics including the choice of induction agents and intravenous fluids in patients with head injury.

Please listen, enjoy and comment. We'd love to hear from you, and don't forget to visit the blog site for additional information, slides and content.

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Iain Beardsell

Vic Brazil of #FOAMed and #SMACC fame came to talk to the St.Emlyn's team in Virchester.

Listen in for top tips on looking great and sounding super.

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Iain and Simon talk through the practicalities of in situ sim in the ED. How do we make it happen in a way that works and helps individuals, teams and departments learn together.

Rick and Iain explore how the latest guidance about the use of high sensitivity troponin was developed and how far we can be assured that it is evidence based.

The NICE guidance is available here. http://www.nice.org.uk/guidance/dg15

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Simon and Iain discuss what might appear to be a rather dull subject, but it's not. Coding is a key to developing your department and also to secure the functions of UK emergency departments.

A great primer for everyone coming up to FCEM and to anyone interested in how Emergency Departments are funded in the UK.

Follow this link to the associated blog post http://stemlynsblog.org/show-money/

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Simon and Nat with a linked podcast to the blog post on the ingestion of button batteries by children.
http://stemlynsblog.org/button-batteries/

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Iain and Simon talk about the upcoming SMACC conference in Chicago and do their very best to persuade you to come to the best conference in the world

The Challenge and Value of Research in Emergency Medicine: at DGINA 2014

Rick Body's talk from DGINA on the need for research in EM.

Check out the associated blog post at http://stemlynsblog.org

Iain Beardsell and Natalie May talk you through a wise and safe approach to the child with moderate shortness of breath. Listen and learn from the St.Emlyn's team.

Iain and Simon discuss the dilemmas of dealing with the patient presenting with chest pain to the ED.

Blog post link here

Next week Iain and Nat will be in London for the best trauma conference in the world. Join them in person, online, on the podcast and on twitter.

Check out the program here, it's amazing.

http://www.londontraumaconference.com/

Have fun :-)

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Whilst I remain in Virchester healing the sick and injured, Nat and Iain are sharing the #FOAMed love at the London Trauma Conference. This is the first round up from day 1 with many highlights and a few tasters for some more podcasts to come.

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Old, young, pregnant, social, airways, cricoid and dogmalysis. There is loads to catch up on from #LTC2014.

Iain and Nat take you through the day.

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It's prehospital and helicopter day at #LTC2014! Iain and guest podcaster Caroline Leech chat through the key points of the day.

A Christmas review of the world of EM, CC and resuscitation #FOAMed.

This review is no way exclusive and focuses on sites that people may not be  familiar with. Take it as read that EMCRIT, LITFL, PHARM, ICN, SGEM, EMLitofNote, ALiEM, Resus.me, KI docs, etc. are already known to be awesome. Check them out and follow the many excellent #FOAMed sites around the world.

Check out the big hitters here http://www.aliem.com/social-media-index/

There are also so many other sites that we have not mentioned, but which we regularly visit and listen to.

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First of our podcasts from the London Trauma Conference.

A fantastic episode with Iain talking to Gareth Davies (from London HEMS) talking about Impact Brain Apnoea.


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St.Emlyn's

The number of patients seen in each ED with problems relating to early pregnancy in the UK is very variable - some hospitals have rapid referral pathways for patients who know they are pregnant. It's still worth thinking about early pregnancy problems though as all EDs see young women and many of these may not yet know that they are pregnant.

Our induction podcast covers our approach to women presenting to the ED

Nat and Iain :-)

Rick Body and Kerstin de Wit discuss the role of NOACs in clinical management. Part 1 addresses the basics, stuff you should know if you are prescribing these drugs.

Part 1 tells us the good stuff, don't forget to listen to 2 and 3 in the next few weeks as not everything is perfect ;-)

Check out the BLOG POST HERE
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Live from the London Trauma Conference 2014. Iain Beardsell interviews Mark Wilson on the need for rapid response, digital technology and the GoodSAM app.

Karim Brohi joins the St.Emlyn's team at the London Trauma Conference to talk on vascular injury and arterial dissection. A whole range of diagnoses that you should not miss, but which is easy to miss.

Tricky!

Check out the blog post that accompanies this podcast here.

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Rick and Kirstin delve deeper into the world of Novel Oral Anti Coagulants.

Do you think you're awesome at assessing shock?

Think again!

The stupendous Prof Tim Harris (who St.Emlyn's loves) tells us that all is not quite as it seems.....

Listen, learn, be awesome.

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Simon and Iain debate how the management of opiate OD has changed in the ED.

Surely you're not still giving massive doses of naloxone IV and IM are you? Really? Maybe this will make you think again.

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A short podcast updating the UK Advanced Paediatric Life Support (APLS) course guidelines for the management of trauma in children.

Don't forget to read the blog post here. APLS Updates: New kids on the block,

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Iain interviews the wonderful Tim Draycott on the management of the Obstetric patient with trauma.Tim is a consultant Obstetrician from Bristol and is a great speaker on this rather terrifying topic!

A first podcast with Simon Laing from the RCEMFOAMed team. We look back at influential trauma related papers from 2014-2015.

Iain and Simon discuss the initial management of severe and life threatening asthma in the resus room.

Another podcast in the induction series aimed at new starters in Emergency Medicine.

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Barbra Backus joins Rick Body to discuss the origin, development and future of risk scores for ED patients with possible acute coronary syndromes. Two researchers at the top of their game, and  authors of the HEART and MACS scores.

Another induction podcast on a common condition in the ED. Back pain in the ED - it's not all musculoskeletal and there are some really risky diagnoses out there that you need to think about.

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Red flag symptoms and analgesia advice below.

Recorded in Chicago at the SMACC US Conference, Nat, Rick, Simon and Iain discuss the day of workshops and look forward to the main conference.

Iain and Simon discuss Iain's SMACC talk and how we deal with difficult cases in the ED.

The first day of #smacc15 was amazing. An incredible introduction and an amazing program.