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.

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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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.

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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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.

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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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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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.

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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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.

Liz Crowe has delivered some great talks at SMACC, and her talents do not stop there. In her real job she is a social worker on PICUs in Australia. She has a wealth of experience at helping people through difficult times and she shares that with us here on the podcast.

In truth this is something we planned to do when we were all in Chicago but the podcast has added poignancy following the tragic death of John Hinds. Although planned as a stand alone subject we cannot help but contextualise the topic in light of recent tragic events.

We hope it helps now and in the future.

RIP John Hinds
Crack the Chest talk at SMACCUS

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St.Emlyn's

Day 2 and 3 at #smaccUS. Iain and Simon round up the highlights and look forward to #smaccDUB.

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A podcast mini to round up and look forward to the next few months on the podcast.

We also have a special recording of Danny Boy from the Irish Youth Choir and conducted by Greg Beardsell. This performance was dedicated to Dr John Hinds in Dublin following his untimely death in a motorcycle accident.

Please listen and take a moment to remember him and all that he has done to inspire everyone involved in the care of the injured.

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Iain and Simon discuss the core skills that all EM clinicians need to manage pain in the ED.

These are the basics, but don't be put off. The basics are more important than the fancy stuff that we will discuss in a later podcast.

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Liz Crowe joins Iain Beardsell to discuss really difficult conversations in the ED. How do we communicate terrible news in the ED and critical care.

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How to make a referral from the ED to an in patient team.

Simon and Nat talk about how to have that tricky conversation when you have to tell a colleague that they may have made a mistake.

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We are truly honored to listen and learn from Dr Youri Yordanov from Paris. Youri was the senior emergency physician on duty on the 13/11/15 during the brutal and terrifying terrorist attacks in Paris. Here he joins St.Emlyn's to discuss how they managed a mass casualty incident with lessons for us all.

There is no doubt that without the skills, preparation and response of Youri, his ED team, the wider hospital and the emergency service in general the death rate would have been much worse.

Thanks Youri for your wisdom and reflections.

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Greetings from the London Trauma Conference!

As has become our pre-Christmas custom, Iain and I have been hanging out at the fabulous London Trauma Conference, hearing about advances and controversies in trauma care and tracking down some of the speakers to find out exactly what they really think (and recording it, for podcasts we'll release in due course).

The conference extends over four days, incorporating the Air Ambulance and Prehospital Day and the Cardiac Arrest Symposium; unfortunately we can't stick around for those but our colleagues over at the RCEM FOAM network will be podcasting from those days too, so keep an eye on their site and podcast feed too.

Iain and Liz discuss how we can manage bad outcomes at Christmas. It's especially tough for patients and their families when tragedy occurs at times when we are all suposed to be festive. It's also tricky for staff and their families. Liz and Iain talk through why we feel like we do and how we can manage ourselves and others better.

Simon and Ross Fisher from Sheffield discuss the emerging role of paediatric surgeons in trauma. This podcast was recorded at the London Trauma Conference (so sorry for a bit of background noise at times).

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Ross and Simon discuss paedatric major trauma systems and quality indicators. Most of this podcast focuses on UK systems and training but should be relevant to all emergency clinicians who deal with injured children.

Iain Beardsell joins Tim Coats, chair of the UK Trauma Audit Network, to discuss the role of trauma units within major trauma networks.

Sandra Viggers and Vic Brazil grace St.Emlyn's with a conference report from Sand Diego and the International Meeting for Simulation in Healthcare (IMSH) #IMSH2016.

Ross Fisher, consultant paediatric surgeon and lead for TARNlet joins Simon Carley at the London Trauma Conference to discuss the challenges in managing paediatric trauma in the UK.

Iain and Liz discuss boundaries and medicine. What do you do when your personal life impacts on your clinical practice.