The St.Emlyn’s Podcast

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

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

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

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

00:00 Introduction and Conference Highlights

01:51 Non-Invasive vs. Arterial Pressure Monitoring

03:28 Intra-Arrest Blood Pressure and ROSC

05:34 Serratus Anterior Plane Blocks for Rib Fractures

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

13:17 HEMOTION Trial

15:01 PRE OXI and BLING III Trials

17:08 Fluid Management in Septic Shock

18:37 Expedited Transfer vs. On-Scene Resuscitation

20:39 Intraosseous vs. Intravenous Access

21:48 Conclusion and Final Thoughts

Join hosts Iain Beardsell and Natalie May at the London Trauma Conference as they welcome Peter Brindley back to the St Emlyn’s podcast. In this engaging episode, they delve into the nuances of social media, digital footprints, and the burgeoning influence of artificial intelligence in medicine. Brindley discusses the importance of maintaining an authentic digital presence and addresses the impact of misinformation and disinformation in the digital age. They explore the challenges and opportunities presented by AI in clinical decision-making and share insights on navigating this evolving landscape as healthcare professionals. Tune in for a thought-provoking conversation on staying relevant and responsible in a digitally-driven world.

In this episode of the St Emlyn's podcast, Iain Beardsell and Simon Carley reflect on their experiences at recent conferences, including the IncrEMentuM 2025 and The Big Sick. They discuss the exceptional quality and innovative formats of presentations at IncrEMentuM, emphasizing the enthusiasm and positive atmosphere. The discussion also covers key emergency medicine topics from February's blog posts, including the maintenance of clinical skills, the importance of diastolic blood pressure in resuscitation, and a systematic review on resuscitative hysterotomy. Additionally, they explore new guidance on the diagnosis of death, particularly in intensive care settings. Special thanks to Galen Pharmaceuticals and PM Cardio for their support.

The Guest - Richard Lyon

The Guest - Dan Dworkis

Dan Dworkis, MD, PhD, FACEP is the Chief Medical Officer at the Mission Critical Team Institute, the founder of The Emergency Mind Project, a board-certified emergency medicine physician, and an assistant professor at the Keck School of Medicine at USC.

His work focuses on the optimal development of mission critical teams in and out of emergency departments. He completed the Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital / Brigham Health, and also earned an MD and PhD in molecular medicine from Boston University School of Medicine. Dr. Dworkis is the author of The Emergency Mind:  Wiring Your Brain for Performance Under Pressure.

In this episode of the St. Emlyn's podcast, hosts Iain Beardsell and Natalie May discuss hyperbaric medicine at the London Trauma Conference with Dr. Jeff Kerrie, an internal medicine physician from Canada. Dr. Kerrie provides insights into dive and hyperbaric medicine, covering the basics of hyperbaric therapy, its applications, and key practices for emergency departments when treating patients with decompression illness. The conversation also touches on misconceptions and unregulated uses of hyperbaric chambers, emphasizing the importance of consulting certified medical professionals.

The Guest

For the last three years, Jeff Kerrie has served as the Island Health Medical Director of Quality, Safety, and Ethics. Dr. Kerrie has a master’s degree in clinical bioethics from Clarkson University/Icahn School of Medicine at Mt. Sinai in New York. Over the last six years, Dr. Kerrie helped build the Island Health ethics program, where he has provided ethics consultations and teaching to staff, patients, and families.

Dr. Kerrie underwent medical training at the University of Manitoba before completing residency in Internal Medicine at UBC. He practices as a general internist in Victoria, and is an Assistant Clinical Professor with the University of British Columbia and the University of Victoria. Other medical work has included medicine in atypical environments (including dive/hyperbaric medicine, ski patrol, and high altitude environments), obesity medicine, and international health. Dr. Kerrie is also a graduate of the Physician Quality Improvement program at Island Health.

In his spare time Dr. Kerrie enjoys aviation, skiing, and SCUBA diving.

The Guest

Mark is a Consultant Neurosurgeon and Pre-Hospital Care Specialist working at both Imperial College (mainly St Mary's Major Trauma Centre) and as an Air Ambulance doctor. 

He am a Clinical Professor specialising in Brain Injury at Imperial and Honorary Professor of Pre-Hospital Care (the Gibson Chair) at the Faculty of Pre-Hospital Care, Royal College of Surgeons, Edinburgh. 

His specialist areas are acute brain injury (mostly traumatic brain injury) and its very early management. He is co-director of the Imperial Neurotrauma Centre and am co-founder of GoodSAM, a revolutionary platform that alerts doctors, nurses, paramedic and those trained in basic life support to emergencies around them. 

Mark have worked extensively overseas (India, Nepal, South Africa, as a GP in Australia, Researcher for NASA and as an expedition doctor on Arctic and Everest expeditions). He also wrote The Medics Guide to Work and Electives Around the World. His research is mainly into the brain in trauma and in hypoxia (using it as an injury model) in humans.

The Guest - Caroline Leech

Caroline Leech is Deputy Clinical Lead of The Air Ambulance Service and has 25 years of prehospital clinical experience.  She is a Consultant in Emergency Medicine at University Hospital Coventry, the West Midlands Trauma Network Director, and the Trauma Lead for the Institute for Applied & Translational Technologies in Surgery (IATTS). Caroline is currently undertaking a NIHR funded Clinical Research Scholarship with Warwick University. Her research interests include maternal out-of-hospital cardiac arrest, calcium in traumatic haemorrhage, and frailty in major trauma. She is committed to improving equality and diversity in PHEM, and promoting strategies for supporting the wellbeing and psychosocial care of prehospital responders.

In this season-ending episode of the St Emlyn's podcast, Iain Beardsell and Simon Carley come together in Zermatt, Switzerland, to discuss recent studies and updates.

They highlight a randomized control trial on early exercise in blunt chest wall trauma, revealing its limited impact on recovery outcomes. Additionally, they explore the long-term safety of intraosseous access based on new evidence from Denmark.

The episode also provides insights into updated imaging guidelines for paediatric trauma and broad considerations on the growing role of AI in healthcare, especially in emergency settings. There are closing remarks on recent blog posts about toxic alcohol poisoning and the Difficult Airway Society meeting, while looking forward to upcoming conferences in Spain and Vienna.

00:00 Welcome to St Emlyn's Podcast

00:31 Exploring the Big Sick Conference in Zermatt

01:25 Evidence-Based Medicine: Early Exercise in Blunt Chest Wall Trauma

04:30 Intraosseous Access: Long-Term Complications

06:37 Imaging Decisions in Pediatric Trauma

09:17 The Promise and Perils of Artificial Intelligence in Healthcare

13:10 Toxic Alcohol Poisoning: A Critical Review

16:17 Conference Highlights and Future Events

19:19 Season 11 Finale and Looking Ahead to Season 12

In this episode of the St Emlyn's podcast, hosts Iain Beardsell and Liz Crowe talk with Nathalie Pattyn at TacTrauma24 in Sweden about the phenomenon of skills fade amongst emergency physicians.

Nathalie discusses her extensive background in medicine, psychology, and neuroscience, and shares insights from her research on how skills can deteriorate during low workload deployments, such as her 15-month clinical stint in Antarctica.

They delve into the lack of systemic measures to address returning to practice after long absences, how cognitive and psychomotor skills are affected by skill fade, and the contrast between teaching technical skills and ensuring they become automatic and stress-resilient.

The conversation highlights the need for evidence-based guidelines to ensure healthcare professionals maintain their proficiency, which ultimately benefits patient care and the healthcare system.

00:00 Introduction and Guest Introduction 00:13 Natalie's Background and Expertise 00:38 Skills Fade in Emergency Medicine

01:01 Personal Experience with Skills Fade

02:14 Regulations and Policies on Skills Maintenance

04:19 Imposter Syndrome vs. De-skilling

06:42 Aviation vs. Medical Field: Skills Certification

08:27 Aging and Cognitive Decline in Medical Skills

09:57 Teaching vs. Training in Medical Education

12:42 Future Directions and Systemic Solutions

14:31 Conclusion and Contact Information

The Guest

Nathalie Pattyn, MD, MPsy, PhD, received a degree in medicine from the Université Libre de Bruxelles (magna cum laude, 2001), a Master in Clinical Psychology from the Vrije Universiteit Brussel (cum laude, 2004), a PhD in Psychological Sciences from the Vrije Universiteit Brussel (2007) and a PhD in Social and Military Sciences from the Royal Military Academy (2007).

She also holds a postgraduate degree in Aerospace Medicine; a postgraduate degree in Emergency Medicine; a postgraduate degree in General Practice ; a postgraduate degree in Disaster Medicine ;and a Master in Global and Remote Healthcare.

She completed her Junior Officer Course with the Belgian Defense College in 2005, and her Staff Officer Course in 2008. She has a mixed clinical, research and operational background, having been deployed as a medical officer in various Middle Eastern and African countries, and having completed missions in Antarctica for a total duration of more than two years.

Her longest deployment was 15 months to the Halley VI Research Station in Antarctica, where she worked as the station physician while setting up a new biomedical research laboratory for the European Space Agency. She is currently still working as an emergency physician and a flight surgeon.

Her research interests include the psychophysiological measures of performance in elite populations; and Human Factors approach to isolated and confined environments, ranging from space to submarines.

In 2010, she founded a research unit within the Royal Military Academy, dedicated to the multidisciplinary study of human performance in operational environments. This led her to be the project manager for designing a tailored Human Performance Program for the tier one unit of the SOF community in Belgium.

She is currently an Associate Professor in Physiopathology at the Vrije Universiteit Brussel and in Human Performance at the Royal Military Academy.

You can read Nathalie's excellent book "Handbook of Mental Performace" for free here.

Welcome to our first episode recorded at the London Trauma Conference 2024.

In this episode, hosts Iain Beardsell and Natalie May are joined by Matt Hooper from Adelaide to discuss his unique career path, from emergency medicine to pre-hospital and retrieval medicine, intensive care, and more recently, palliative and end-of-life care.

The conversation centres around the principles of end-of-life care, particularly in acute and traumatic scenarios, and how these can be integrated with life-saving efforts. Key points include the challenges of shifting focus from survival to quality of death, the importance of recognizing and supporting witnesses and caregivers, and the concept of 'compassionate resuscitation.'

Practical tools such as the 'pause' are also explored, aiming to humanize highly charged medical environments and potentially prevent burnout and PTSD among healthcare providers.

00:00 Introduction and Guest Welcome

01:00 Key Messages on Death and Palliative Care

02:12 Challenges in End-of-Life Care

03:20 Improving Quality of Death and Relationships

04:32 Emotional Impact on Care Providers

06:41 Navigating End-of-Life Conversations

12:17 Practical Applications in Intensive Care

16:41 The Pause: A Tool for Reflection 21:58 Conclusion and Final Thoughts

The Guest - Matt Hooper

Matt is an accomplished intensive care specialist with a diverse background in emergency medicine, prehospital & retrieval medicine, and palliative care.

Notable for his leadership in developing critical care service models, he founded South Australia’s MedSTAR Emergency Medical Retrieval Service. He has also co-authored a highly regarded case-based text book and held key teaching and examining roles nationally and internationally in prehospital and retrieval medicine.

With a strong focus on high-performance teams working within high acuity, high consequence environments, Matt's expertise has also extended to human factors in healthcare, cardiothoracic intensive care, ECMO, and clinical ultrasound. More recently however, he has pivoted towards palliative and end of life care, pursuing a Master's degree at Cardiff University and consulting at Mary Potter Hospice in Adelaide. He is passionate about exploring new and innovative ways to prevent potentially avoidable suffering and enhance end of life outcomes for patients in acute care clinical environments.

In this episode of the St Emlyn's podcast, hosts Iain Beardsell and Liz Crowe speak with Sean Brayford Harris, a paramedic and interoperability development officer with the London Ambulance Service, about the development of the 10 second triage tool—a new, streamlined method for triaging casualties in high-stress environments like major incidents.

They discuss its creation and implementation, including collaboration with the Metropolitan Police and other emergency services. Key points include the shortcomings of the previous 'sieve and sort' system, the challenges of developing a simplified tool, and the benefits of this new approach for non-medical first responders.

The episode emphasizes the importance of cross-team collaboration in emergency scenarios and the potential impact of the tool on reducing distress and improving outcomes for both responders and patients.

00:00 Introduction

00:37 Background on Major Incident Triage

01:01 Challenges with Existing Triage Systems

01:15 Designing the 10 Second Triage Tool

05:16 Implementing the Triage Tool

06:50 How the 10 Second Triage Tool Works

13:48 Real-World Applications and Benefits

18:54 Conclusion and Final Thoughts

During Winter's Challenges, Iain Beardsell and Simon Carley reviewed the November 2024 blog posts for St Emlyn's podcast, marking the start of 2025. They discuss the busy state of emergency departments, critical incidents, and the importance of maintaining a learning culture.

They highlight the upcoming Big Sick Conference in Zermatt and the IncrEMentuM in Spain, noting their potential benefits for networking and education.

Simon emphasizes creating a psychologically safe environment and fostering curiosity, growth, and knowledge-sharing among emergency department staff. They also review a range of medical studies, including those on small bore vs. large bore chest tubes for haemothorax, intra-arrest arterial blood pressure monitoring, and the new GLP-1 receptor antagonists for obesity treatment.

Lastly, they address the importance of handling bad behavior in the team and maintaining kindness and professionalism, even during high-stress periods.

00:00 Introduction and New Year Greetings

00:35 Current State of Emergency Departments

01:17 Upcoming Conferences: The Big Sick and IncrEMentuM

03:43 Building a Learning Culture in Emergency Medicine

12:24 Pre-Hospital ECPR and ECMO

13:58 Small Bore vs Large Bore Chest Tubes

17:37 Intra-Arrest Arterial Blood Pressure Monitoring 24:01 New Drugs and Toxicology

24:47 Care in the Hot Zone

27:12 Addressing Bad Behaviour in Emergency Departments

30:42 Conclusion and Future Plans for St Emlyn's

In this episode of the St. Emlyn's podcast, Rick Body and Greg Yates delve into the concept of likelihood ratios, an advanced yet practical tool for diagnosing patients in the emergency department. Building on the previous episode about predictive values, they explain how likelihood ratios help compare the probability of test results between diseased and non-diseased patients. They provide examples, like evaluating chest pain and using the Smith Calculator for Anterior ST Elevation, to show how likelihood ratios can change clinical decision-making.

Rick and Greg also discuss Bayesian reasoning and how pretest and post-test probabilities are used in practice.

00:00 Introduction to the Podcast

00:34 Understanding Likelihood Ratios

02:05 Practical Example: Chest Pain Case

03:53 Calculating Likelihood Ratios

07:17 Applying Bayesian Reasoning

09:50 Recap and Conclusion

In this episode of the St Emlyn's podcast, Iain Beardsell and Simon Carley provide a comprehensive update for October 2024. They discuss key blog posts covering diverse medical topics, including highlights from the Royal College of Emergency Medicine's academic science conference focusing on toxicology, high-potency opioids, novel benzodiazepines, and the use of flumazenil.

They also explore the Green ED project and the impact of climate change on healthcare. Additionally, they delve into recent research on ventricular fibrillation pad positions, the use of tranexamic acid (TXA) in trauma care, and the importance of maintaining a positive outlook amidst winter challenges by seeking small wins and engaging in enjoyable aspects of emergency medicine. The episode offers valuable insights and updates for emergency medicine professionals.

00:00 Welcome and Introduction

01:27 Highlights from the Royal College of Emergency Medicine Conference

01:50 Toxicology Insights: High Potency Opioids and Benzodiazepines

05:11 Climate Change and Healthcare: The Green ED Project

08:23 Medical Conferences: A Phoenix from the Ashes

10:38 Ventricular Fibrillation and Pad Position: New Insights

17:22 Tranexamic Acid (TXA) in Trauma Care

24:01 Maintaining Positivity in Challenging Times

In this episode of the St Emlyn's podcast, Iain Beardsell and Natalie May reflect on their experiences at the London Trauma Conference, a four-day event covering various aspects of trauma and pre-hospital care.

They discuss key takeaways from sessions on cardiac arrest, including talks on perioperative cardiac arrest and the prognostication of cardiac arrest patients.

The episode also delves into wellness in the medical field, featuring insights from senior emergency physician Rod McKenzie and pre-hospital expert Matt Hooper on practical psychosocial care. Additionally, the podcast highlights advancements in trauma care, defibrillation strategies, and the importance of correct pad placement and basic practices.

The episode underscores the holistic approach to patient care and the significance of personal well-being for medical professionals.

00:00 Welcome to the St Emlyn's Podcast

00:52 Highlights from the London Trauma Conference

01:13 Cardiac Arrest Symposium Insights

03:53 Prognostication After Cardiac Arrest

06:44 Defibrillation Strategies and Basics

08:29 Wellness and Mental Health in Emergency Medicine

11:10 Palliative Care in Pre-Hospital Settings

12:32 Trauma Conference Highlights and Innovations

16:48 Poster Presentations and Stand-Up Science 17:58 Key Takeaways and Reflections

18:43 Closing Remarks

In this episode of the St Emlyn's podcast, hosts Iain Beardsell and Liz Crowe are joined by Chris Bishop, a clinical research fellow at the Centre for Trauma Sciences at Queen Mary University of London. Chris discusses his PhD research on veno-arterial ECMO support for cardiogenic shock following major trauma haemorrhage and explains the principles and applications of ECMO, particularly in trauma patients. The conversation covers the current practices, challenges, and future directions in the use of ECMO for trauma care, including multidisciplinary decision-making, patient selection criteria, and pioneering techniques like selective aortic arch perfusion and emergency preservation and resuscitation.

00:00 Introduction

01:12 Understanding ECMO and Its Applications

02:20 ECMO in Trauma Patients

04:17 Challenges and Resistance in ECMO Adoption

05:36 Current Research and Practices

11:31 Future Directions in Trauma Resuscitation

13:28 Conclusion

This episode, recorded live at Tactical Trauma 24 explores the concept of bad behaviour within high-performing medical teams. Liz Crowe, who will be well known to regular listeners, discusses what constitutes bad behaviour, its impacts on team dynamics and patient safety, and the importance of self-awareness among medical professionals.

Key findings from recent research highlight that even subtle actions like eye-rolling can negatively affect patient safety as much as overt harassment. The speaker emphasises the importance of psychological safety, trust, competence, authenticity, consistency, and empathy in maintaining a healthy team environment. Practical advice includes assessing one's own behaviour and seeking honest feedback from colleagues and loved ones.

Comprehensive show notes are available here

00:00 Introduction: Addressing Bad Behaviour

01:18 Defining Bad Behaviour

01:49 Impacts of Bad Behaviour

03:15 Psychological Safety and Team Dynamics

04:24 Personal Experiences and Observations

05:46 Types of Bad Behaviour

07:19 Research Findings on Workplace Behaviour

09:10 Self-Awareness and Behavioural Impact

14:21 The Karpman Drama Triangle

17:29 Conclusion and Final Thoughts

In this episode of the St Emlyn's podcast, Iain Beardsell and Simon Carley discuss various facets of emergency medicine.

They highlight a study on patient experience in emergency departments, focusing on issues like loss of autonomy, unmet expectations, and vulnerability. Suggestions for improvement include better communication, effective signage, and patient comfort.

The podcast also covers a 'dirty adrenaline drip' study from Australia, emphasizing remote inotrope management.

Discussions include the use of arterial blood pressure monitoring in pre-hospital settings and the merits of CT scans beyond the traditional six-hour window for diagnosing subarachnoid haemorrhage.

The episode wraps up with reflections on the positives of emergency medicine and the importance of maintaining enthusiasm and mastery in the field.

Join Iain Beardsell and Liz Crowe in an engaging discussion with Alice Hutton, an emergency physician from Paris, at Tactical Trauma 24 in Sundsvall, Sweden.

The episode delves into the implementation and logistics of pre-hospital eCPR (Extracorporeal Cardiopulmonary Resuscitation) by SAMU in Paris. Alice shares insights from her PhD research on refractory cardiac arrest and discusses the use of therapeutic hypothermia, including experimental approaches like total liquid ventilation.

Key topics include team composition, decision-making for patient eligibility, real-time management strategies, bypassing traditional emergency rooms for specialized facilities, and the challenges of scene management, family communication, and post-event debriefing.

This conversation offers a comprehensive look at the latest innovations that could transform pre-hospital emergency medical services.

Read more here...

00:00 Introduction and Guest Introduction

01:29 eCPR in Paris: Current Practices

02:35 Dispatch and Response Protocols

03:32 On-Scene Procedures and Challenges

04:23 Decision Making and Scene Management

05:53 Training and Handling Difficult Situations

06:59 Challenges of eCPR Decision-Making

08:07 Importance of Team Debriefing

08:52 Post-Resuscitation Procedures

10:12 Operational Logistics and Success Rates

11:20 Innovative Research in Therapeutic Hypothermia

13:13 Future of Pre-Hospital Cooling Techniques

13:46 Conclusion and Final Thoughts

In this episode of the St. Emlyn's podcast, hosts Iain Beardsell and Simon Carley share their insights from recent conferences, including Gateshead's RCEM scientific conference, Tactical Trauma 24 in Sweden, and the Premier Conference.

They explore 'Goldilocks moments' for executing life-saving procedures in critical care, emphasizing optimal timing for interventions like thoracotomies. The episode also discusses innovative training methods like shadowboxing to enhance decision-making in high-stress medical scenarios. In addition, they review a significant trial on smoking cessation in emergency departments, highlighting its potential role in broader public health initiatives, including sexual health and HIV screening.

Discussions also cover various pain management strategies, such as the use of intranasal vs. intravenous Ketorolac for renal colic. The hosts critique the traditional peer review process in medical research and advocate for open peer review to support equitable and accessible scientific publishing.

00:00 Introduction and Catching Up

02:07 The Goldilocks Moment in Critical Care

05:25 Training and Decision-Making in Emergency Procedures

07:23 Smoking Cessation in Emergency Departments

10:07 Challenges in Implementing Preventive Health Strategies

10:38 Successful Public Health Projects in Emergency Medicine

11:19 Exploring Alternative Interventions in Emergency Departments

11:52 Highlights from the Premier Conference

12:54 Intranasal Ketorolac for Pain Management

15:46 The Future of Peer Review in Medical Research

20:09 Concluding Thoughts and Upcoming Content

In this episode, recorded at Tactical Trauma 2024, Andrew Petrosoniak discusses real-world experiences in trauma care, and the innovative use of simulation to resolve systematic issues in blood delivery and overall trauma resuscitation protocols.

Key takeaways include the concept of intelligent failure, reducing cognitive overload for medical staff, and the creation of efficient medical environments. Moreover, the episode delves into the significant improvements achieved through simulation, such as a 50% reduction in blood delivery times, and the integration of performance data to enhance CPR and clinical space design. Emphasizing the importance of using data to drive improvements, the conversation explores the implementation of roles like a CPR coach and the scalable application of these practices across individual, team, and systemic levels.

Listeners are encouraged to view failures constructively and leverage simulations and data for better patient outcomes and team performance.

00:00 Introduction to Simulation in Emergency Medicine

01:05 A Real-Life Trauma Case

02:18 Identifying Systemic Issues

02:46 Implementing and Testing Solutions

05:45 The Concept of Intelligent Failure

09:41 Scaling and Impact of Simulation

10:22 The Power of Simulation in Experimentation

10:56 Data Integration in Healthcare and Sports

11:29 Evaluating CPR Quality Through Simulation

12:14 Using Data to Improve Clinical Performance

13:47 Designing Clinical Spaces with Simulation Data

15:28 Scaling Impact with Simulation

18:02 Efficient Team Communication in Trauma Bays

19:04 Broadcasting and Recording Simulations for Education

19:39 Conclusion and Future Directions

The Speaker

Dr. Andrew Petrosoniak is an emergency physician and trauma team leader at St. Michael’s Hospital and an Assistant Professor in the Department of Medicine at the University of Toronto. He has completed a Master of Science in medical education where he focused on the use of in situ simulation (practice in the actual workplace) in procedural skill acquisition.

Andrew’s field of research includes in situ simulation and simulation-based technical skill acquisition. His work focuses on usability testing and the identification of personnel- and systems-based safety threats within acute care medicine. He is the principal investigator of the TRUST study (Trauma Resuscitation Using in Situ simulation for Team Training) that includes a partnership with human factors experts to evaluate systems and processes during high-stakes trauma simulations.

Recorded at Tactical Trauma 2024, in this episode of the St. Emlyn’s podcast, Iain Beardsell and Liz Crowe sit down with Kevin Cyr, commander of a SWAT-like unit in the Royal Canadian Mounted Police, to discuss leadership, failure, and resilience in high-stakes environments. Kevin shares the powerful story of a tragic hostage situation that resulted in the unintended death of the hostage by the police, a failure of the highest order. Through this  tragedy, Kevin highlights the importance of visible leadership, team resilience, and learning from failure in both law enforcement and healthcare settings.

Key Themes:

1. Handling Failure in High-Pressure Situations:
Kevin discusses a significant incident where a hostage was killed by his SWAT team during a rescue attempt, describing it as the “epitome of failure.” This tragic event not only made national news but left an indelible mark on the team. The podcast dives into the lessons learned from this event and how the team used it to drive growth and improvement. In healthcare, much like in policing, failure can feel devastating and highly public, but it’s also a critical aspect of development for teams and leaders.

2. Visible Leadership and Unwavering Support:
In the aftermath of a traumatic event, Kevin emphasizes the importance of leadership being present and supportive. He recounts how he and his commanding officer went to visit the officers involved in the shooting immediately after the event, providing what he calls “unwavering support.” In healthcare, leaders should adopt similar strategies, offering visible and sustained support to their teams in the immediate aftermath of difficult cases.

3. Sustained Support Over Time:
While initial support following a traumatic event is crucial, Kevin points out that it’s often after 48 hours, or even weeks later, that people start feeling isolated. Leaders must continue to check in with their teams weeks after the event, when the immediate crisis may have passed, but the emotional toll is still present. This ongoing visibility and emotional support are key to retaining staff and ensuring their well-being in both law enforcement and healthcare.

4. Debriefing to Learn, Not to Blame:
Kevin advocates for a debriefing process that focuses on learning from failure rather than assigning blame. After their tragic event, his team didn’t just move on; they dissected the event to understand what went wrong and how to prevent similar failures in the future. In healthcare, this process is equally valuable—debriefs should aim to identify learning opportunities and reinforce positive actions, not to point fingers.

5. The Role of Organizational Culture:
Kevin touches on how organizational apathy, or a lack of emotional and psychological support, can cause more damage than the actual traumatic event itself. He highlights the importance of developing a high-trust environment where team members feel safe to express vulnerability. In healthcare, fostering a culture of open communication and mutual support is essential to prevent burnout and moral injury.

6. The Value of Failure in Team Growth:
One of the most profound insights Kevin shares is the idea that failure is a necessary part of growth. Three years after their tragic hostage situation, his team was called to a similar event, but this time they were successful in rescuing both hostages. Kevin attributes this success directly to the lessons learned from their earlier failure, emphasizing that failure, when handled correctly, can lead to transformational change.

7. Selection and Resilience in High-Performance Teams:
Kevin discusses the importance of selecting team members with high emotional intelligence and the humility to ask for help when needed. He explains how his team differentiates between rank and role, giving autonomy to those with the most subject matter expertise, regardless of their rank. In healthcare, this is a critical point—leaders must recognize that true leadership isn’t just about authority, but about empowering others to take charge when appropriate.

8. Managing Expectations and Mental Health:
The episode also delves into how individuals in high-stakes roles, whether in policing or healthcare, cope with the psychological aftermath of traumatic events. Kevin explains how his team has shifted from the belief that emotional support is unnecessary to recognizing the value of helping team members process their experiences in a healthy way. This parallels the increasing focus in healthcare on preventing burnout and ensuring emotional well-being through proactive support.

Key Takeaways:

- Failure is Inevitable: In high-stakes environments like policing and healthcare, failure will happen. What matters is how teams respond to failure—learning from it, growing stronger, and preventing future mistakes. Leadership Requires Visibility: Leaders must be present, especially in the aftermath of failure. Showing unwavering support and maintaining visibility over time is crucial for maintaining team morale and trust.

- Debriefing to Learn: After a failure, it’s essential to have structured debriefs that focus on learning and improving, rather than blaming. This helps teams identify areas of improvement and ensures they grow stronger from difficult experiences.

- Long-Term Support is Critical: Immediate support after a traumatic event is important, but equally important is sustaining that support over time, checking in with team members weeks or even months later to ensure their well-being.

- Resilience through Humility: Teams should be built on trust and humility, where members can ask for help when needed and offer help to others. Selecting individuals with high emotional intelligence is key to creating a resilient team.

- Failure Leads to Growth: When handled correctly, failure can drive transformational change within teams. It allows for the development of new skills and ensures that teams are better prepared for future challenges.

Quotes:

- “Failure is a necessary part of growth. It’s not just something to get over, it’s something you get better from.”
- “Visible leadership and unwavering support are critical in the immediate aftermath of failure. Your team needs to know you’re there with them.”
- “Debriefing to learn, not to blame, is essential. We must focus on what went well, what went wrong, and how to improve next time.”
- “In high-pressure environments, we can’t control every variable, but we can control how we respond to them and how we prepare for the future.”

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

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

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

00:00 Introduction and Summer Updates

00:55 Upcoming Conferences and Events

01:44 Manchester Acute Coronary Score (MACS) Review

05:30 AI in ECG Analysis with Steve Smith

08:18 Non-Fatal Strangulation Awareness

10:45 Reboa: Pre-Hospital Use and Insights

14:11 Pediatric Emergency Medicine Highlights

14:36 Eating Disorders and Diabetes Management

19:00 Lidocaine Patches for Rib Fractures

21:46 Critical Appraisal and Medical Statistics

24:28 Button Battery Ingestion Dangers

26:12 Conclusion and Farewell

In this episode of the St Emlyn's podcast, Iain Beardsell is joined by Dan Horner, a consultant in Emergency Medicine and Neurocritical Care, and Tom Roberts, an Emergency Medicine Registrar and clinical lecturer, to discuss their recently published SHED study on subarachnoid haemorrhage in the Emergency Department (ED). This landmark study, published in the Emergency Medicine Journal, explores the safety of CT scans in diagnosing subarachnoid haemorrhage up to 24 hours after headache onset and evaluates the role of further investigations like a lumbar puncture.

The study examines acute severe headache presentations in the ED and the diagnostic approach to ruling out subarachnoid haemorrhage, a critical and often feared diagnosis among emergency physicians. Conducted through the Trainee Emergency Research Network (TURN), the study included over 3,600 patients from 88 UK EDs with acute severe headaches reaching maximum intensity within one hour and no focal neurology. Data collection included CT scans, lumbar puncture results, and 28-day follow-up to identify missed cases of subarachnoid hemorrhage.

Key findings from the study revealed a 6.5% prevalence of subarachnoid haemorrhage, with a significant number presenting within six hours of headache onset. The sensitivity of CT scans remained high beyond the traditional six-hour window, suggesting that CT alone could safely rule out subarachnoid haemorrhage up to 18 hours in many cases, potentially reducing the need for lumbar puncture. The risk of missing an aneurysmal subarachnoid haemorrhage after a negative CT was found to be extremely low, around 1 in 1,000.

These findings challenge the routine use of lumbar puncture in patients presenting beyond six hours if the CT scan is negative, potentially changing ED practice and reducing unnecessary invasive procedures. The discussion also emphasized the importance of shared decision-making and recognizing that diagnostic testing is about managing probabilities, not certainties. For clinicians, the episode highlights the need to expedite CT scans for patients with acute severe headaches, especially those presenting within 10 minutes of onset, as they are more likely to have significant pathology. Emergency physicians are encouraged to own the decision-making process for ruling out serious causes of headaches and not defer solely to 'specialists'.

The SHED study supports extending the diagnostic window for CT scans in ruling out subarachnoid hemorrhage up to 18 hours, reducing the need for lumbar puncture in many cases. This data empowers emergency clinicians to make informed decisions, manage patient expectations, and streamline ED processes. 

For more information, listeners are encouraged to read the SHED Study in the Emergency Medicine Journal and explore the related blog post on the St Emlyn’s website. Emergency clinicians are also invited to connect with TERN to get involved in future research opportunities. 

This episode provides valuable insights for clinicians in managing acute severe headaches, emphasizing a more nuanced approach to subarachnoid hemorrhage diagnosis and the importance of clinical decision-making in the ED.

In this episode, we delve into the critical role of neuroprotection in pre-hospital care, particularly in pediatric head injuries. Through a real-life case study of a 13-year-old boy who suffered a traumatic brain injury after being hit by a car, we explore the steps taken by paramedics and critical care teams to stabilize him and prevent further neurological damage. From airway management to advanced interventions, this episode highlights the challenges of pre-hospital neuroprotection and the incredible teamwork that led to the patient’s remarkable recovery. 

There is more detail on the full blogpost here. 

This podcast was recorded live at the Hope Church in Winchester as part of the PREMIER conference. We are grateful to the organizing team for hosting us and allowing us to use the audio. The PIER and PREMIER websites are full of amazing resources for anyone working in Paediatric Emergency Medicine, and we highly recommend them.

The Speaker

Ed is a Speciality Trainee in Emergency Medicine in Wessex and a trainee Critical Care Practitioner with Dorset and Somerset Air Ambulance. Ed is also the co-founder and Managing Director of Enhanced Care Services, a Southampton-based company delivering enhanced and critical care to the event medical sector, providing frontline ambulance services across Hampshire and clinical education at all levels, employing over 200 clinicians. Ed holds the Diploma in Immediate Medical Care (RCSEd) and, having promised to not take on any more work, is currently undertaking a Masters in Resuscitation, Pre-hospital and Emergency Medicine at QMUL.

Enhanced Care Services

Enhanced Care Services' mission is to provide and influence excellent patient care, irrespective of injury, illness or location, through the delivery of high-quality clinical operations and education. Founded in 2015, ECS now provide frontline ambulance operations across the South, delivers extensive medical cover to some of the most prestigious events across the UK and provides education from its bespoke education centre in Southampton and beyond.

In this episode, Dr Tim Warlow, a consultant in Paediatric Palliative Care, explores the complexities of caring for children with life-limiting conditions in the emergency department (ED). The discussion highlights the increasing prevalence of paediatric life-limiting conditions and the growing medical complexity of these cases, which pose significant challenges for ED staff.

The episode begins by clarifying what paediatric palliative care truly involves. Contrary to common misconceptions, palliative care is not about withdrawing care but rather enhancing the quality of life for children from the point of diagnosis, whether the condition is present from birth or develops as the child deteriorates. This proactive approach often involves increasing the level of care and support as the child’s needs evolve.

As the number of children with life-limiting conditions continues to rise, EDs are encountering more medically complex cases, including children who are technology-dependent and require high levels of care at home. These challenges are compounded by the evolving expectations of parents, who are often better informed and more involved in their child's care decisions. Post-COVID, community services have struggled to recover, particularly in nursing support, making the role of the ED even more critical.

The episode provides practical tips for ED professionals to better manage these cases. Key strategies include:

1. Recognising Life-Limiting Conditions: With over 400 recognized life-limiting conditions and many more undiagnosed, it’s crucial to assess whether a child might have palliative care needs.

2. Listening to Families: Families often have an intimate understanding of their child’s unique medical baseline. Listening deeply to their insights, even when they seem unusual, is essential for providing appropriate care.

3. Building Rapid Rapport: Quickly establishing a connection with the family is vital, as these children can deteriorate rapidly. Acknowledging the child’s presence, summarizing the situation, and validating the family’s experience can help build trust.

4. Understanding the Child Beyond Their Illness: Families worry that healthcare professionals only see their child when they are unwell. Taking the time to learn about the child’s life outside of the hospital can lead to better care decisions.

5. Reading the Advanced Care Plan: If available, review the child’s advanced care plan before discussing the case with the family. This ensures that the family doesn’t have to recount their entire journey and that care decisions are based on the most current information.

The episode also addresses the importance of being aware of unconscious prejudice. Healthcare professionals must ensure that decisions are based on the child’s specific needs rather than assumptions about their quality of life due to their disability.

In conclusion, the episode emphasizes that while caring for children with life-limiting conditions in the ED is challenging, it is also deeply rewarding. The key to providing excellent care lies not just in medical interventions but in being present, listening, and supporting the family through difficult times. Whether things go as planned or not, your presence and compassion are what families remember most.

This episode is a must-listen for anyone involved in pediatric care, offering valuable insights into the critical role of the ED in supporting children with life-limiting conditions and their families. There is more detail on the blogpost here. 

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

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

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

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

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

In this podcast from the PREMIER conference 2024, Francesca Stedman, a consultant paediatric surgeon from Southampton Children's Hospital discusses the care of the child who has ingested a button battery. 

Button batteries are ubiquitous and come in various types and sizes. There are about 85 different kinds available or in use in the UK alone, found in everything from toys to hearing aids. The most notorious is the CR2032, which is about 20 millimeters in diameter and 3.2 millimeters thick. It contains lithium manganese oxide, and while its small size makes it convenient for electronics, it poses a significant risk if ingested.

The danger with button batteries lies in their potential to cause severe injuries when lodged in the esophagus. They can cause necrosis, which is essentially tissue death, due to a strong alkaline substance produced by the battery. This substance acts like a potent oven cleaner, rapidly causing damage. The esophagus has three natural narrowing points where these batteries often get stuck, increasing the likelihood of injury. The situation becomes critical very quickly, often within two hours of ingestion.

One of the most concerning aspects of these incidents is that button battery ingestions are rarely witnessed. Children might present with vague symptoms like drooling, difficulty swallowing, or even just being generally unwell. These can easily be mistaken for other common illnesses, leading to delays in diagnosis. In one particularly harrowing case, a child presented multiple times with symptoms of a respiratory infection, only for an x-ray to reveal a button battery lodged in the esophagus. By then, the damage was extensive.

When ingestion is suspected, immediate action is crucial. Getting a chest x-ray is the first step, and if necessary, a lateral x-ray can confirm the presence of a button battery by revealing a characteristic double rim or halo sign. Pre-hospital measures can include giving honey or jam, depending on the child’s age, to help mitigate the damage. However, these should never delay getting the child to the hospital.

Once at the hospital, the primary goal is to remove the battery as quickly as possible to prevent further injury. Depending on the location of the battery and available specialists, either ENT surgeons or paediatric surgeons may perform the removal. Post-removal care involves monitoring for complications like perforations or fistulas, which can develop days or even weeks later. In severe cases, these injuries can lead to life-threatening conditions, such as aorto-esophageal fistulas, which require immediate surgical intervention.

In summary, button battery ingestion is a serious and often underappreciated risk. Even in homes where precautions are taken, accidents can happen. The key is quick recognition and action. As parents and caregivers, we need to be vigilant about keeping these small, dangerous objects out of children's reach. And if an accident does occur, immediate medical attention is essential to minimize the risk of serious injury. 

More details are available on the blogpost here. 

In this St. Emlyn's podcast, Rick Body and Greg Yates, continue our exploration of diagnostic test accuracy, shifting our focus to positive predictive value (PPV) and negative predictive value (NPV). These concepts are vital for anyone preparing for exams or looking to enhance their application of diagnostic tests in clinical practice. While our last podcast discussion centred on sensitivity and specificity, PPV and NPV offer a different, arguably more clinically practical perspective on interpreting test results.

Positive predictive value (PPV) and negative predictive value (NPV) are essential tools for understanding the effectiveness of diagnostic tests. PPV helps us determine the likelihood that a patient with a positive test result actually has the condition, whereas NPV helps us gauge the probability that a patient with a negative test result does not have the disease. These values are crucial for making informed clinical decisions, particularly when considering the prevalence of a condition in the population. Today, we’ll delve into these concepts, their practical applications, and why it's important to consider both PPV and NPV alongside sensitivity and specificity.

You can find more about this on the St Emlyn's Blog and please don't forget to like and subscribe.

In today's episode, taken from live recordings at PREMIER 2024, we dive into an increasingly common treatment for type 1 diabetes: hybrid closed loop insulin pumps. We'll begin with a brief overview of traditional insulin pumps and explain how hybrid closed loops are different. The core of our discussion will be centered around three case studies, illustrating potential scenarios you might encounter in a pediatric emergency department and how to manage them effectively.

With NICE's recent technology appraisal advocating for universal access to hybrid closed loop systems for all type 1 diabetes patients, it's crucial to understand these devices. Over the next few years, you'll likely encounter these systems frequently. We'll cover the essentials of how these pumps work, their benefits, and potential issues that might arise, such as connectivity problems, cannula issues, and handling intercurrent illnesses.

Join us as we explore the revolutionary impact of hybrid closed-loop systems, which offer better glucose control and significantly improve the quality of life for those with type 1 diabetes.

Dr Nicola Trevelyan has been the Clinical Lead for the Paediatric Diabetes Service in Southampton for the last 20 years. During this time, she has seen huge changes in the management of CYP with diabetes.  She has been involved in several large multicentre trials for paediatric diabetes,  helping to better our understanding of how best to use new technologies in diabetes management in children and move forward access to new treatment technologies.  She was one of the founding committee members for the Assoc of Children's Diabetes Clinicians (ACDC) in 2006 and has been on working parties for BSPED helping evidence base and re-write the national DKA guidelines in 2020 and for the National Paediatric Diabetes Audit.  For the last 4 years, she has been on the Clinical Advisory Group for the RCPCH Quality Improvement Programme for Paediatric Diabetes. 

It was a huge pleasure to sit down with Steve Smith, a name synonymous with ECG expertise. Steve, renowned worldwide for his influential ECG blog, has been a pivotal figure in advancing our understanding of ECGs. Many of us have honed our ECG skills thanks to Steve’s insights. I had the opportunity to meet Steve about a decade ago at one of the SMACC conferences. Today, we delve into the fascinating world of occlusive myocardial infarction (OMI) and its comparison to STEMI (ST-elevation myocardial infarction), and explore the promising future of artificial intelligence in ECG interpretation.

In this special episode of the St Emlyn's podcast, we explore the concept of occlusive myocardial infarction (OMI) and its distinctions from ST elevation myocardial infarction (STEMI). Dr. Smith discusses his extensive work and experience in emergency medicine, spanning over three decades, and his development of Dr. Smith's ECG blog. The conversation dives into the limitations of traditional STEMI criteria and the benefits of adopting the OMI paradigm. Additionally, they discuss the revolutionary potential of artificial intelligence in ECG interpretation, particularly through the Queen of Hearts program developed in collaboration with Powerful Medical. Dr. Smith shares compelling studies and real-world applications demonstrating the efficacy of AI in diagnosing ECGs, ultimately offering a promising future for enhanced patient outcomes.

00:00 Introduction

01:43 Steve Smith's Journey in Emergency Medicine and ECGs

02:45 The Evolution of ECG Diagnosis: From STEMI to OMI

03:55 Challenges and Resistance to the OMI Paradigm

07:10 Key Indicators of Occlusive Myocardial Infarction

09:25 The Role of Artificial Intelligence in ECG Diagnosis

11:03 Development and Implementation of the Queen of Hearts AI

14:28 Clinical Studies and Real-World Applications

21:10 Future Prospects and Final Thoughts

A comprehensive blog post with references is available here

In this episode of the St Emlyn's podcast, Iain Beardsell introduces a talk by Anna Kyle, a consultant paediatrician from Somerset, delivered at the Premier conference in June 2024. Anna explores the complexities of assessing and managing eating disorders in young patients, including young adults. Highlighting the critical nature of eating disorders, she notes a 90% increase in admissions over five years and emphasizes the deadly risks, particularly anorexia nervosa with its 10% lifetime mortality rate. Kyle provides detailed guidance on recognizing symptoms, conducting risk assessments, and the importance of a thorough medical evaluation. She also touches on the MEAD guidance for managing eating disorders, stressing effective communication with patients and their families, and the critical role of empathy and support throughout the treatment process.

00:00 Introduction to the Podcast

01:03 The Deadly Nature of Eating Disorders

02:23 Medical Complications of Eating Disorders

05:08 Cardiovascular and Other Systemic Effects

07:22 Risk Assessment and MEAD Guidance

10:23 Communication and Management Tips

15:24 Conclusion and Final Thoughts

Comprehensive notes can be found here

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

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

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

The sudden death of anyone is a tragic event, but even more so a child, particularly when it comes completely unexpectedly. We've all seen stories in the papers or even been involved in caring for these young people. In this podcast Harshil Dhutia talks about the common causes fo sudden cardiac death, and gives a roadmap for the investigation of young people with worrying symptoms and ongoing care for their families.

There are more details in the comprehensive post on the St Emlyn's blog site

This podcast was recorded live at the Hope Church in Winchester as part of the PREMIER conference. We are grateful to the organising team for hosting us and allowing us to use the audio. The PIER and PREMIER websites are full of amazing resources for anyone working in Paediatric Emergency Medicine and we recommend them highly.

The Speaker

Harshil Dhutia is a consultant cardiologist at Glenfield Hospital, University Hospitals of Leicester the lead for inerited cardiac conditions service in the region, providing specialist care for patients with genetic heart diseases and their family members. He is a International Board of Heart Rhythm Examiners certified heart rhythm specialist for all aspects of cardiac device implantation and management including pacemakers, defibrillators and cardiac resynchronisation therapy. He is an expert in sports cardiology and has extensive clinical and research interests in the management of competitive and recreational athletes with cardiovascular disease. He is the medical lead for the Joe Humphries Memorial Trust, a Leicestershire based charity that raises awareness of sudden cardiac death in young people and provides cardiovascular resuscitation and AED training in schools, sports clubs and to members of the community.

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

You can find an in-depth set of shownotes on St Emlyn's. Please do also like and subscribe, wherever you get your podcasts.

This month's content includes...

Recommended Conferences

Premier Conference - 11th-12th June 2024, Winchester

Tactical Trauma 24 - 7th-9th October, Sundsvall, Sweden

RCEM Annual Scientific Conference

After the bumper double paper review episode, we fit two months of blog content into one episode. Iain and Simon discuss the management of the patient with chronic liver disease who has an acute decompensation, global health connections, whether mechanical CPR is more effective than human CPR and the potential effects on elderly patients staying in the ED overnight.

References

Conor Crowley, Justin Salciccioli, Wei Wang, Tomoyoshi Tamura, Edy Y. Kim, Ari Moskowitz, The association between mechanical CPR and outcomes from in-hospital cardiac arrest: An observational cohort study, Resuscitation, 2024, 110142, ISSN 0300-9572, https://doi.org/10.1016/j.resuscitation.2024.110142.

Roussel M, Teissandier D, Yordanov Y, Balen F, Noizet M, Tazarourte K, Bloom B, Catoire P, Berard L, Cachanado M, Simon T, Laribi S, Freund Y; FHU IMPEC-IRU SFMU Collaborators; FHU IMPEC−IRU SFMU Collaborators. Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Intern Med. 2023 Dec 1;183(12):1378-1385. doi: 10.1001/jamainternmed.2023.5961. PMID: 37930696; PMCID: PMC10628833.

Recommended Conferences

Premier Conference - 11th-12th June 2024, Winchester

Tactical Trauma 24 - 7th-9th October, Sundsvall, Sweden

RCEM Annual Scientific Conference

In this second of a two part podcast special Iain and Simon go through twenty of the top papers from the last year or so, as presented by Simon at the Big Sick Conference in Zermatt earlier this year. All the details and more discussion can be found on the blog site.

In Part 2 they discuss papers about major haemorrhage, trauma, cardiac arrest and more. 

In Part 1 they discuss all things airway, including where we should be intubating patients needing immediate haemorrhage control. VL vs DL, the effect of blade size on intubation success, whether small adult ventilation bags are better than larger versions, intubating comatose poisoned patients, and more. 

Papers

Jansen JO et al. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA. 2023 Nov 21;330(19):1862-1871. doi: 10.1001/jama.2023.20850. PMID: 37824132; PMCID: PMC10570916.

Davenport R et al. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial. JAMA. 2023 Nov 21;330(19):1882-1891. doi: 10.1001/jama.2023.21019. PMID: 37824155; PMCID: PMC10570921.

PATCH-Trauma Investigators and the ANZICS Clinical Trials Group; Prehospital Tranexamic Acid for Severe Trauma. N Engl J Med. 2023 Jul 13;389(2):127-136. doi: 10.1056/NEJMoa2215457. Epub 2023 Jun 14. PMID: 37314244.

Shepherd JM et al Safety and efficacy of artesunate treatment in severely injured patients with traumatic hemorrhage. The TOP-ART randomized clinical trial. Intensive Care Med. 2023 Aug;49(8):922-933. doi: 10.1007/s00134-023-07135-3. Epub 2023 Jul 20. PMID: 37470832; PMCID: PMC10425486.

Bouzat P et al. Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial. JAMA. 2023 Apr 25;329(16):1367-1375. doi: 10.1001/jama.2023.4080. PMID: 36942533; PMCID: PMC10031505.

Torres CM, Kent A, Scantling D, Joseph B, Haut ER, Sakran JV. Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers. JAMA Surg. 2023 May 1;158(5):532-540. doi: 10.1001/jamasurg.2022.6978. Erratum in: JAMA Surg. 2023 Apr 5;: PMID: 36652255; PMCID: PMC9857728.

Marsden MER, Kellett S, Bagga R, Wohlgemut JM, Lyon RL, Perkins ZB, Gillies K, Tai NR. Understanding pre-hospital blood transfusion decision-making for injured patients: an interview study. Emerg Med J. 2023 Nov;40(11):777-784. doi: 10.1136/emermed-2023-213086. Epub 2023 Sep 13. PMID: 37704359; PMCID: PMC10646861.

Wohlgemut JM, Pisirir E, Stoner RS, Kyrimi E, Christian M, Hurst T, Marsh W, Perkins ZB, Tai NRM. Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome. Trauma Surg Acute Care Open. 2024 Jan 12;9(1):e001214. doi: 10.1136/tsaco-2023-001214. PMID: 38274019; PMCID: PMC10806521.

Cheskes S, Verbeek PR, Drennan IR, McLeod SL, Turner L, Pinto R, Feldman M, Davis M, Vaillancourt C, Morrison LJ, Dorian P, Scales DC. Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med. 2022 Nov 24;387(21):1947-1956. doi: 10.1056/NEJMoa2207304. Epub 2022 Nov 6. PMID: 36342151.

Siddiqua N, Mathew R, Sahu AK, Jamshed N, Bhaskararayuni J, Aggarwal P, Kumar A, Khan MA. High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial. Emerg Med J. 2024 Jan 22;41(2):96-102. doi: 10.1136/emermed-2023-213285. PMID: 38050078.

Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. 2023 Feb;40(2):108-113. doi: 10.1136/emermed-2021-212294. Epub 2022 Sep 30. PMID: 36180168.

Patterson T, Perkins GD, Perkins A, Clayton T, Evans R, Dodd M, Robertson S, Wilson K, Mellett-Smith A, Fothergill RT, McCrone P, Dalby M, MacCarthy P, Firoozi S, Malik I, Rakhit R, Jain A, Nolan JP, Redwood SR; ARREST trial collaborators. Expedited transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicentre, parallel, randomised clinical trial. Lancet. 2023 Oct 14;402(10410):1329-1337. doi: 10.1016/S0140-6736(23)01351-X. Epub 2023 Aug 27. PMID: 37647928.

Issa EC, Ware PJ, Bitange P, Cooper GJ, Galea T, Bengiamin DI, Young TP. The “Syringe Hickey”: An Alternative Skin Marking Method for Lumbar Puncture. J Emerg Med. 2023 Mar;64(3):400-404. doi: 10.1016/j.jemermed.2023.01.013. PMID: 37019501.

In this two part podcast special Iain and Simon go through twenty of the top papers from the last year or so, as presented by Simon at the Big Sick Conference in Zermatt earlier this year. All the details and more discussion can be found on the blog site.

In Part 1 they discuss all things airway, including where we should be intubating patients needing immediate haemorrhage control. VL vs DL, the effect of blade size on intubation success, whether small adult ventilation bags are better than larger versions, intubating comatose poisoned patients, and more. 

Check out part 2 for papers about major haemorrhage, trauma, cardiac arrest and more.

Papers

Dunton Z, Seamon MJ, Subramanian M, Jopling J, Manukyan M, Kent A, Sakran JV, Stevens K, Haut E, Byrne JP. Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery. J Trauma Acute Care Surg. 2023 Jul 1;95(1):69-77. doi: 10.1097/TA.0000000000003907. Epub 2023 Feb 28. PMID: 36850033.

Prekker et al: Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults August 3, 2023 N Engl J Med 2023; 389:418-429 DOI: 10.1056/NEJMoa2301601

Landefeld KR, Koike S, Ran R, Semler MW, Barnes C, Stempek SB, Janz DR, Rice TW, Russell DW, Self WH, Vonderhaar D, West JR, Casey JD, Khan A. Effect of Laryngoscope Blade Size on First Pass Success of Tracheal Intubation in Critically Ill Adults. Crit Care Explor. 2023 Mar 6;5(3):e0855. doi: 10.1097/CCE.0000000000000855. PMID: 36895888; PMCID: PMC9990830.

Snyder BD, Van Dyke MR, Walker RG, Latimer AJ, Grabman BC, Maynard C, Rea TD, Johnson NJ, Sayre MR, Counts CR. Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. Resuscitation. 2023 Dec;193:109991. doi: 10.1016/j.resuscitation.2023.109991. Epub 2023 Oct 5. PMID: 37805062.

Freund Y et al. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391. PMID: 38019968; PMCID: PMC10687712.

Eastwood G et al, TAME Study Investigators. Mild Hypercapnia or Normocapnia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2023 Jul 6;389(1):45-57. doi: 10.1056/NEJMoa2214552. Epub 2023 Jun 15. PMID: 37318140.

Downing J, et al. Prevalence of peri-intubation major adverse events among critically ill patients: A systematic review and meta analysis. Am J Emerg Med. 2023 Sep;71:200-216. doi: 10.1016/j.ajem.2023.06.046. Epub 2023 Jun 28. PMID: 37437438

It's episode one of season 11 and Simon and Iain chat through the blog content from St Emlyn's from January 2024. There's discussion about New Year resolutions and how to make them habits, intubating poisoned patients with a decreased conscious level and what we can possibly do to improve the working conditions in our Emergency Departments.

As ever, we hope you enjoy the podcast. Please do like and subscribe, and if you'd like to contribute to St Emlyn's in any way please get in touch. 

It's the last episode of season 10 and Iain and Simon discuss December 2023's blog posts. In a packed podcast they discuss prehopsital blood transfusion decision making, E-scooter injury patterns, the potential for AI in medicine and selective aortic arch perfusion.

Please do get in touch if you would like to contribute to St Emlyn's and as ever do like and suscribe and tell your friends (if you think the podcast is any good). 

Mentioned in the podcast

• Gary Klein - Streetlights and Shadows
• Critical Appraisal Nugget - Semi Structured Interviews
• EMCrit - Shadowboxing
• EMCrit - Interview with Gary Klein
• A Skeptic's Guide to Emergency Medicine
• Life in the Fast Lane - What is AI and How Does it Work
• T-MACS scores
• Homo Deus: A Brief History of Tomorrow by Yuval Noah Harari 
• East Anglia Air Ambulance RAID Conference

In this bumper double edition Simon and Iain chat through all the recent content on the St Emlyn's blog site, including a review of CRYOSTAT-2 and the DAShED study, a review of the new ILCOR guidelines, flow in the ED and why silence might just be the tonic we all need.

All of us at St Emlyn's wish you all, wherever you are on the world a peaceful, happy and restful Christmas. 

Please do like and subscribe and get in touch if you'd like to contribute to our ongoing work. 

One of the benefits of the use of online platforms for meetings is the ability to record and disseminate talks more widely. This is an edited version of a talk given by Dr Andy Curry, Consultant Cardiothoracic Intensive Care Consultant at University Hospital Southampton, covering the origins of Extra Corporeal Membrane Oxygenation (ECMO) right up to the present day. Throughout the talk, he gives real world experience, coupled with a knowledge of the literature to communicate all you could ever want to know about this fascinating and potentially very exciting therapy. 

References

Peek GJ, Clemens F, Elbourne D, Firmin R, Hardy P, Hibbert C, Killer H, Mugford M, Thalanany M, Tiruvoipati R, Truesdale A, Wilson A. CESAR: conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure. BMC Health Serv Res. 2006 Dec 23;6:163. doi: 10.1186/1472-6963-6-163. PMID: 17187683; PMCID: PMC1766357.

Stub D, Bernard S, Pellegrino V, Smith K, Walker T, Sheldrake J, Hockings L, Shaw J, Duffy SJ, Burrell A, Cameron P, Smit de V, Kaye DM. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 2015 Jan;86:88-94. doi: 10.1016/j.resuscitation.2014.09.010. Epub 2014 Oct 2. PMID: 25281189.

Belohlavek J, Smalcova J, Rob D, et al. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2022;327(8):737–747. doi:10.1001/jama.2022.1025

Martje M. Suverein, M.D., Thijs S.R. Delnoij, M.D., et al. Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. The INCEPTION trial. N Engl J Med 2023; 388:299-309. DOI: 10.1056/NEJMoa2204511

The Alfred ECPR Role Cards

The Bottom Line ECMO Reviews

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

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

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

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

Welcome to a bumper edition of the podcast discussing content from St Emlyn's for June 2023.

In this episode, Simon and Iain talk about DL vs VL, the PATCH trial, drug pushers, packers and stuffers, the new head injury guidelines from NICE and the AMAX4 algorithm and much more.

If you would like to submit something to St Emlyn's for consideration we'd love to hear from you.

Times are tough in the NHS at the moment, but we hope at St Emlyn's we can remind you of all the best parts of the incredibly important and rewarding job we do.

Take care. 

The clue to these is very much in the Title – BRUE is a diagnosis in itself. Children often do weird stuff, but they rarely do weird scary stuff.

In this talk, Jilly goes talks through how we can define these events as high and low risk and gives us tools to manage these patients (and their parents)

Along with colleagues, Jilly has written a guideline for BRUE, the full version of which you can find here

Jilly also mentions a flowchart from Peds Cases, which you can find here

There is also this superb blog post from Natalie May on the St Emlyn's website which accompanies this podcast, which goes through some really useful cases.

As a Wessex ST7 in Paediatric Emergency Medicine (RCPCH), Jilly Boden currently works in Queen Alexandra Hospital (Portsmouth).  Her specialist interests include acute stabilisation and transfer of the critically ill patient, having spent a year with the 'Southampton & Oxford Retrieval Team' (SORT) and hopes to find a way of combining this with her future PEM career.

Jilly has a passion for education, particularly 'PEM to the non-paediatrician', including international teaching of the tri-service military GPs, and being on the national committee to write a new standardised paramedic paediatric curriculum.

In her free time (you know, apart from the kids and all that) she works as part of the track medical team for the 'British Motorcycle Racing Club', providing pre-hospital care to high velocity polytrauma patients in the 'golden hour' following collisions often exceeding 120mph. 

This episode of the podcast is a live recording from the PREMIER Conference of John O Neil discussing penetrating injuries with learning points that are useful for clinicians who look after both adult and paediatric patients. 

There are three main mechanisms – violence, impalement and self harm, although the first is by far the most common. 

Penetrating injuries are rare but have significant morbidity and mortality. The key is early and accurate diagnosis, and many can be managed conservatively. The distribution of penetrating injuries across the UK differs widely, with most in the London area, although as seen in the news recently can happen anywhere.

Remember how traumatic it is to be a trauma patient. We put you on a bed, cut off your clothes, stick needles in you and take your family away. Some will also just not engage with you (teenage boys particularly) making assessment difficult. Be kind. Don’t get frustrated.

Physiologically there may be a strong vagal response that can hide some of the signs we’d expect. Also, bear in mind the events prior to the injury – the child may have been running a considerable distance (before and after the incident) raising their lactate (but don’t assume this is the cause). Children tend to ‘fall off a cliff’ – they appear well, but can suddenly decompensate – keep the momentum to definitive management going and do not be falsely reassured.

John mentioned a great friend of St Emlyn’s Vic Brazil and we would heartily endorse you have a look at her work.

You can find more information about the Reducing Knife Crime initiative here

Chris brought us his reflections amnd knowledge from some of his extensive experience as a military EM consultant in two wars. Blast injury could be blunt, penetrating, may involve major haemorrhage: you have to expect any injury possible. It’s worldwide and it’s getting more common. 

Blast injury affects every body cavity, but it is the CABC approach that matters, Doing the basics well is still the key. Bleeding points may not be obvious so apply tourniquets wherever stops the bleeding.

Often patients will not arrive in ones or twos but as a whole group affected by an incident, so it is vital we are prepared. The Paediatric Blast Injury Field Manual is a free resource available to download here and is highly recommended.

Chris Hillman is a Consultant in Emergency Medicine and Paediatric Emergency Medicine, working in Southampton. Serving in the Royal Navy since university, he has deployed on Ships, Submarines and with Commando units globally, and with the Army to Afghanistan and Iraq. He is the outgoing Consultant Advisor in Emergency Medicine and Clinical Director Commando Forward Surgical Group.