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

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.

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, 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

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, 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.

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 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. 

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. 

A special double edition covering the blog posts from November and December and more. We discuss evidence based medicine with the DoseVF trial, and more from RECOVERY, discussion about 'what is downtime' and how we organise follow up for patients who don't live in our area and what happened at the amazing London Trauma Conference

We also announced some of the plans for StEmlynsWILD. Look out for booking details and more in the coming weeks. 

Simon chats to Sarah Thornton, consultant anaesthetist, intensivist and head of the NW school of anaesthesia on preparing to work in a critical care unit during the Covid-19 pandemic.

Iain and Simon chat about the current Corona pandemic and the blog in Feb 2020.

Iain remains positive, but Simon thinks the glass is half full. Time will tell who is right (though in truth there is a lot of common ground).

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

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

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

The Resuscitationist: More Than Just a Title

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

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

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

Decompensated Liver Disease: A Growing Concern in the ED

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

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

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

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

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

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

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

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

Expanding Education: The MSc in Emergency Medicine

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

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

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

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

Introducing Coda: The Next Evolution After SMACC

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

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

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

The Zero Point Survey: A Game-Changer in Resuscitation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

St. Emlyn's Podcast: Key Insights from May in Emergency Medicine

As we transition into the warmer months, it's an opportune time to reflect on recent discussions and developments within the field of emergency medicine, particularly those highlighted in the latest episode of the St. Emlyn's podcast. This episode covered a wide range of topics, from workplace safety to advancements in pediatric care and innovative approaches in patient management. Below is a comprehensive summary of the key points discussed.

Workplace Safety: A Pressing Concern

The podcast began with a reflection on a recent violent incident at Newham Emergency Department (ED), which served as a stark reminder of the dangers healthcare professionals face daily. Emergency departments, by their very nature, are open and accessible, making them vulnerable to violent incidents. This recent attack has prompted a nationwide reassessment of safety measures, with many EDs enhancing their protocols to protect staff.

The conversation emphasized that violence in the workplace should never be normalized. It’s crucial that healthcare professionals feel safe and supported in their working environment. Leadership within departments plays a critical role in this, not only by implementing robust safety protocols but also by fostering a culture of solidarity and mutual support among staff. The incident at Newham underscores the need for constant vigilance and proactive measures to ensure the safety of everyone working in emergency medicine.

Leadership in Education: Simon Carley’s New Role

In more positive news, Simon Carley’s recent appointment as the CPD (Continuing Professional Development) lead for the college was discussed. This role is a significant milestone, not just for Simon but also for the integration of modern educational approaches within formal medical education. Simon’s involvement with St. Emlyn's has long been focused on innovative, social media-driven education, and this new role offers an opportunity to bring these methods into a broader educational framework.

The appointment highlights the value of combining traditional education with the dynamic, accessible formats offered by the #FOAMed (Free Open Access Meducation) community. It’s a recognition that medical education can benefit from new perspectives and that the integration of these ideas can enhance the learning experiences for healthcare professionals.

Pediatric Status Epilepticus: Evaluating Second-Line Agents

The discussion moved to a detailed analysis of pediatric status epilepticus, focusing on the findings from two key trials: the Eclipse trial and the ConSEPT trial. These studies compared the efficacy of levetiracetam (Keppra) and phenytoin as second-line agents for stopping seizures in children.

The trials found no significant difference between the two drugs in terms of their effectiveness, which has led to debate within the medical community about whether to switch from phenytoin to levetiracetam. While levetiracetam is perceived as easier to administer and safer, the lack of a clear superiority has left the decision somewhat open. However, the ease of use and safety profile of levetiracetam make it an appealing option, and some institutions are considering making the switch.

For clinicians, the takeaway is that while both drugs are viable options, the choice may ultimately come down to individual preferences and institutional protocols. The trials underscore the importance of continuous evaluation of treatment options, particularly in complex cases like pediatric seizures.

Understanding Clinical Trials: The Importance of Statistical Literacy

Simon Carley also highlighted the importance of understanding the statistical nuances in clinical trials, particularly the difference between demonstrating a difference between treatments and establishing their equivalence. This distinction is crucial for accurately interpreting research findings and making informed clinical decisions.

The discussion emphasized that clinicians must be cautious in how they interpret trial results, particularly when it comes to determining whether treatments are genuinely equivalent or if the lack of a significant difference merely reflects the study’s design. This level of critical appraisal is essential for ensuring that new research is applied correctly in clinical practice.

Prolonged Field Care in the ED: Learning from Military Medicine

Another topic discussed was prolonged field care, a concept borrowed from military medicine that is becoming increasingly relevant in emergency departments due to overcrowding and delays. Rich Carden introduced the HITMAN mnemonic—Hygiene and Hydration, Infection, Tubes, Medication, Analgesia, and Nutrition—as a framework for managing patients who are stuck in the ED for extended periods.

The HITMAN approach ensures that patients' fundamental needs are met even when resources are stretched. This method helps prevent complications and improves patient outcomes, even in less-than-ideal conditions. The approach is particularly relevant in today’s healthcare environment, where EDs are often overwhelmed and patients may wait longer than usual for admission or transfer.

Atrial Fibrillation: Reassessing Cardioversion Strategies

Atrial fibrillation (AF) management was another key topic. A recent study in the New England Journal of Medicine compared immediate cardioversion with a wait-and-see approach in patients with new-onset AF. The study found that a wait-and-see approach was non-inferior to immediate cardioversion, with 69% of patients in the wait-and-see group spontaneously cardioverting within 48 hours.

This finding challenges the traditional approach of immediate cardioversion and suggests that in many cases, a more conservative approach may be just as effective. However, the decision should be made through shared decision-making with the patient, taking into account their preferences and the specific circumstances of their condition. This patient-centered approach ensures that treatment decisions are made collaboratively and with the patient’s best interests in mind.

Traumatic Cardiac Arrest: Reevaluating Chest Compressions

The podcast also touched on the evolving management of traumatic cardiac arrest, particularly the role of chest compressions. Recent studies, including one involving porcine models, suggest that in cases of hypovolemic traumatic cardiac arrest, chest compressions may not be beneficial and could even be harmful. Instead, the focus should be on addressing the underlying cause, such as restoring circulating volume.

This shift in practice highlights the importance of understanding the specific etiology of cardiac arrest and tailoring resuscitation efforts accordingly. Communicating these changes to the entire resuscitation team is crucial, as there may be resistance to deviating from traditional protocols. Ensuring that everyone is on the same page and understands the rationale behind the approach is key to successful implementation.

Virtual Reality in Pain Management: An Emerging Tool

Virtual reality (VR) is emerging as a promising tool in pain management, particularly in pediatric patients undergoing painful procedures. A recent study discussed in the podcast found that children who used VR experienced less distress during procedures compared to those who received standard care.

VR offers an innovative, accessible method for managing pain and anxiety, and its use is likely to expand in the coming years. The ability to create immersive environments that distract patients during procedures has the potential to improve patient experiences and outcomes, not just in children but potentially in adults as well.

The Power of Peer Review: Enhancing Clinical Practice

Finally, Simon Carley discussed the importance of peer review in clinical practice. Peer review is a valuable tool for continuous improvement, allowing clinicians to receive feedback from colleagues on their performance. While it can be challenging to create a culture where feedback is welcomed and constructive, the benefits are significant.

Peer review helps clinicians avoid complacency, stay up-to-date with best practices, and continually refine their skills. It’s a simple, cost-effective way to ensure that healthcare professionals are delivering the highest standard of care. Creating a supportive environment where feedback is seen as an opportunity for growth rather than criticism is essential for the success of peer review initiatives.

Conclusion

The discussions in this month’s St. Emlyn's podcast highlight the complexities and challenges of working in emergency medicine, from ensuring workplace safety to staying current with evolving practices. By engaging with new research, embracing innovative tools like virtual reality, and fostering a culture of continuous improvement through peer review, we can continue to advance the field and improve patient care. As always, the St. Emlyn's blog and podcast remain valuable resources for staying informed and connected with the latest developments in emergency medicine.

Highlights from March 2019: Key Insights and Updates

Welcome to the St Emlyn's podcast. I'm Simon Carley and today; I'll be taking you through the highlights from our blog in March 2019. This was a busy month filled with exceptional content, insightful trips, and significant conferences. Let's dive into the details and explore some key topics, starting with adult congenital heart disease, top trauma papers, and the importance of responsible volunteering.

Management of Adult Congenital Heart Disease

March kicked off with an important post on the management of adult congenital heart disease (ACHD). This topic is particularly close to my heart as the hospital I work at is a level two centre for ACHD in the UK. Services have become centralized, and surgical components are now managed at a few specialized centres, with Liverpool being the hub for my region.

Despite this centralization, we still encounter a large population of ACHD patients in our area. These patients often present complex medical histories and unique pathologies that can be challenging to manage in emergency settings. The guidance available typically focuses on chronic and surgical management, but emergency care for these patients requires a different approach.

Common Issues in ACHD Patients

ACHD patients commonly present with dysrhythmias, which can be particularly challenging to manage. Chest pain is also prevalent, although the incidence of ischemic heart disease isn’t significantly higher in ACHD patients, except for those who have undergone certain procedures like the switch operation. Other common issues include:

• Cyanotic patients: Those with single ventricle physiology and right-to-left shunts.
• Endocarditis: A rare but serious complication.
• Non-cardiac problems: Managing ACHD patients with conditions like appendicitis or pneumonia can be complex due to their unique circulatory dynamics.

The bottom line is that these patients often require specialized management strategies. When ACHD patients present with cardiac complications, we consult our local cardiologist or the ACHD centre. However, non-cardiac issues in ACHD patients also warrant discussion with the ACHD centre to ensure comprehensive care.

Key Takeaways for Emergency Physicians

Emergency physicians should familiarize themselves with the unique aspects of Fontan circulation, which relies on venous return based on venous pressure. Aggressive interventions like CPAP, bagging, and diuretics can be detrimental. Understanding these nuances is crucial for providing optimal care.

A Deeper Dive into Fontan Circulation

The Fontan procedure, a surgical intervention for single ventricle defects, creates a unique circulatory system that can be difficult to manage in emergency settings. Unlike normal circulation, Fontan physiology depends heavily on passive blood flow from the veins to the lungs. This means that increasing intrathoracic pressure through methods like CPAP or bagging can reduce cardiac output and worsen the patient's condition.

Fontan patients are particularly vulnerable to fluid shifts and pressures, making careful management of intravenous fluids and medications essential. Understanding these dynamics can be life-saving in the ED. For example, while diuretics might seem a reasonable choice for a patient with fluid overload, they can lead to dangerously low preload and cardiac output in a Fontan patient.

Top Trauma Papers from the Trauma UK Conference

Next up, we revisited some of the top trauma papers presented at the Trauma UK conference. These papers covered a range of topics, from the use of bougies in the ED to bag-mask ventilation during hypertensive resuscitation. Here are some key highlights:

The PAMPer Trial

The PAMPer trial examined the use of prehospital plasma in trauma patients and found significant survival benefits. This trial has important implications for trauma care protocols, emphasizing the potential of early plasma administration to improve outcomes.

The trial showed that administering plasma before hospital arrival can reduce mortality rates in severely injured patients. This finding supports the concept of damage control resuscitation, aiming to stabilize patients early and prevent coagulopathy, acidosis, and hypothermia—the lethal triad in trauma.

Bougie Use in the ED

Another focal point was the utility of bougies in emergency airway management. Evidence suggests that bougies can significantly improve first-pass success rates in difficult intubations, making them a valuable tool in the ED.

A study highlighted at the conference demonstrated that the use of a bougie, even in routine intubations, could increase the success rates for first-pass intubations. This is particularly important in prehospital settings and emergency departments where difficult airways are common.

Late Presenting Head Injury Patients

A paper from Hull explored the management of patients presenting with head injuries more than 24 hours post-injury. The findings indicated that these patients have a significant incidence of important findings on CT scans, suggesting that delayed presentations should not be underestimated.

This study challenges the conventional exclusion of late-presenting head injury patients from acute imaging protocols. It suggests that significant injuries can still be present and warrant immediate attention, even if the patient presents days after the initial trauma.

The Zero Point Survey

The Zero Point Survey, which emphasizes situational awareness, team dynamics, and environmental control before initiating the primary survey, was also highlighted. This approach can significantly enhance resuscitation efforts, ensuring a more organized and effective response.

The Zero Point Survey encourages clinicians to prepare mentally and physically before patient contact. By assessing the situation, assembling the right team, and ensuring the environment is conducive to optimal care, clinicians can improve outcomes and reduce errors in high-stress scenarios.

Responsible Volunteering Overseas

One of the most thought-provoking posts of the month came from Stefan Brisions, discussing the need for responsible volunteering overseas. Volunteering in low and middle-income countries can be incredibly rewarding, but it’s essential to approach it with the right mindset and framework.

The Ethics of Volunteering

Stefan emphasized the importance of volunteering within a system that has sustainability and benefits for all parties involved. There have been concerns about individuals volunteering for personal gain rather than genuine altruism. It’s crucial to ensure that our efforts are focused on creating lasting, positive impacts.

Volunteering should always aim to build local capacity rather than create dependency. This means working with local healthcare providers to enhance their skills and infrastructure, ensuring that the benefits of volunteering continue long after volunteers have left.

Volunteering Responsibly

If you're considering volunteering abroad, it’s vital to engage with established organizations that have a clear mission and ethical framework. This ensures that your contributions are meaningful and aligned with the needs of the local community. Our discussions with experts like Shweta Gidwani, Hooling Harrison, Jennifer Hulls, and Najee Rahman offer valuable insights into this complex issue.

Case Study: Volunteering in South Africa

Kat Evans, who works in Mitchell’s Plain in South Africa, shared her experiences at St Emlyn’s Live. Kat discussed the challenges of working in a resource-limited environment, particularly in managing trauma and toxicology cases.

Her insights into managing trauma in a high-volume, low-resource setting were eye-opening. Kat also shared fascinating details about the use of high doses of atropine for poisoning cases, highlighting the unique medical practices required in such environments.

Kat’s presentation underscored the value of structured volunteer programs that integrate volunteers into local healthcare systems, providing both valuable learning experiences and much-needed support to local healthcare providers.

The Future of SMACC: CODA

March also marked the end of an era with the final SMACC conference in Sydney. SMACC has been a cornerstone for many in the emergency and critical care communities, offering unparalleled opportunities for learning and networking. However, the spirit of SMACC lives on in its successor, CODA.

CODA: A New Beginning

CODA aims to build on SMACC's successes while addressing broader health issues such as vaccination, climate change, and healthcare inequality. The goal is to leverage the engaged community SMACC created to drive meaningful change on a global scale.

CODA plans to tackle these global health issues by bringing together a diverse group of professionals, including those outside the traditional medical fields. This interdisciplinary approach aims to create innovative solutions to some of the world’s most pressing health challenges.

Looking Ahead

While we bid farewell to SMACC, we look forward to the new opportunities CODA will bring. Its emphasis on tackling significant health challenges aligns with the evolving needs of the global healthcare community, promising an exciting future.

What to Expect from CODA

CODA will continue the tradition of high-quality content and dynamic presentations that SMACC was known for. However, it will also incorporate new elements focused on global health advocacy and interdisciplinary collaboration. Expect to see more discussions on how healthcare professionals can contribute to solving broader societal issues.

Additional Highlights from March

Critical Appraisal Nuggets (CANS) on P-values

We also introduced a mini podcast series called Critical Appraisal Nuggets (CANS) focusing on p-values, featuring myself and Rick Body. P-values are a common topic in exams and critical appraisal, and understanding them is crucial for interpreting medical research.

This less-than-ten-minute podcast provides a concise overview of p-values, helping clinicians and students alike grasp this important concept. By demystifying p-values, we aim to enhance our audience's critical appraisal skills, enabling better evidence-based practice.

Dual Coding in Medical Education

Nick Smith, a recent addition to the St Emlyn's team and a brilliant clinical educator, shared insights on dual coding. Dual coding involves using both verbal and visual information to enhance learning and retention.

Nick’s post emphasized how our brains struggle to process multiple streams of information simultaneously. Effective teaching and communication require a balance between verbal explanations and visual aids, ensuring that learners can absorb and retain information without being overwhelmed.

The Impact of Reboa in Trauma Care

Zaf Qasim, a great friend of ours over in the US, examined the impact of Resuscitative Endovascular Balloon Occlusion of the Aorta (Reboa) in trauma care. This post, based on a paper published in JAMA Surgery, analyzed Reboa success rates in civilian trauma using a US database.

The findings suggested that Reboa was associated with higher mortality rates compared to similar patients who did not receive Reboa. This raises important questions about patient selection and the overall benefits of Reboa in trauma care.

Zaf’s post highlighted the need for ongoing research and evidence to determine Reboa's true value. While there are compelling pathophysiological arguments for its use, the clinical outcomes must be scrutinized to ensure it is applied appropriately and effectively.

The Role of Evidence-Based Practice

At St Emlyn's, we prioritize evidence-based practice in all aspects of emergency medicine. The discussions around Reboa, p-values, and dual coding all reinforce the importance of using high-quality evidence to guide clinical decisions and educational strategies.

Final Thoughts

March 2019 was a month of incredible learning and growth. From managing complex ACHD patients to discussing the ethics of volunteering and exploring cutting-edge trauma research, we covered a wide range of topics that are crucial for emergency medicine professionals.

Stay Connected

As we move forward, we encourage you to stay connected with St Emlyn’s for more insights, updates, and discussions. Follow our blog, participate in our events, and join the conversation on social media. Together, we can continue to advance the field of emergency medicine and make a difference in the lives of our patients.

Thank you for joining us this month. Enjoy your practice, and we’ll be back with more great content in April. Have fun, stay safe, and keep learning!

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

St. Emlyn's January Roundup: Key Insights and Innovations

Hello and welcome to the St. Emlyn’s Podcast. I’m Simon Carley, joined by Rick Body. Today, we’re bringing you our January roundup, sharing the most intriguing and impactful content we've covered this month. From reflecting on 2018 to exploring new guidelines and innovations in emergency medicine, we have a lot to discuss. Let’s dive in!

Reflecting on 2018: Transformational Reads and Achievements

As we started January, we reflected on 2018, a year filled with significant achievements and insights. One standout discussion was our review of key books that left a lasting impact. A personal favorite of mine is "Why We Sleep" by Matthew Walker. This book has been transformational for me, influencing how I live and advise others on health, well-being, and performance. The insights on sleep’s importance in education, creativity, and overall health are profound.

Rick, did anything from our 2018 review resonate with you?

Rick Body: Absolutely, Simon. The variety of books we discussed was impressive. It was enlightening to hear about others' achievements in 2018 and their goals for 2019. This exercise really focused my mind on what I hope to achieve this year.

Goals for 2019: Innovations and Personal Aspirations

As we moved from reflections to aspirations, we set our sights on exciting projects for 2019. One major highlight is the AI incubator for emergency care. This initiative aims to support academic careers and foster partnerships between data and industry to enhance medical technologies. It’s an exhilarating time for advancements in emergency care.

Rick is incredibly busy with groundbreaking work, particularly in diagnostics in Manchester. His research and speaking engagements are making waves in the medical community. For more details on these projects, check out the blog where all the information is comprehensively covered.

New Year’s Resolutions: Insights from Liz Crowe

We explored New Year’s resolutions with Liz Crowe, who offered a fresh perspective on well-being and resolutions. Instead of focusing on all-or-nothing goals, Liz suggests starting small and seeking rewards rather than punishments. This approach makes significant lifestyle changes more manageable and sustainable. Committing to resolutions publicly or with a friend can enhance accountability and success.

Rick, do you have any New Year’s resolutions?

Rick Body: It’s challenging to pinpoint one or two, but Liz’s advice on avoiding binary thinking is crucial. Recognizing progress rather than dwelling on setbacks can make a big difference.

Tetanus Guidelines: New Insights and Practical Applications

In January, we delved into updated tetanus guidelines, highlighting significant changes. Previously, a single booster in your early 20s was deemed sufficient, but the new guidelines recommend a 10-year booster. This change stems from the recognition that immunity wanes over time. Interestingly, point-of-care testing is now available to detect active tetanus immunization, allowing for more tailored booster decisions.

These updates are crucial for emergency physicians to ensure compliance with current standards and provide optimal patient care. The blog post simplifies these guidelines, making them accessible and easy to understand.

Excellence in Emergency Medicine: Claire Richmond’s Contributions

We featured Claire Richmond, a hero in the emergency medicine community. Claire, who works with Sydney HEMS, delivered an inspiring keynote at the St. Emlyn’s live conference. Her talk focused on excellence, performance, training, and development in retrieval medicine. She emphasized the importance of honesty, feedback, and continuous improvement.

For those aspiring to achieve self-actualization in emergency medicine, Claire’s insights are invaluable. We’ve shared the video and podcast of her talk, and we highly recommend checking them out.

Prognosticating Cardiac Arrest Outcomes: Dan Horner’s Research

Another highlight of January was Professor Dan Horner’s discussion on serum neurofilament light chains, a promising tool for prognosticating cardiac arrest outcomes. This research, stemming from the TTM trial, suggests that these biomarkers can provide early predictions about patient outcomes. Early identification of patients likely to have poor neurological outcomes can significantly impact family discussions, treatment decisions, and overall management.

This research is groundbreaking and holds potential for future clinical applications, although it’s not yet ready for immediate practice.

Celebrating Evidence-Based Medicine: Critical Appraisal E-Book

We’re incredibly proud of our journal club series at St. Emlyn’s, which advocates for evidence-based medicine. This series highlights the latest research, making it accessible and understandable. To celebrate the contributions over the past year, we’ve compiled an e-book available for free download. This resource is a testament to our commitment to advancing medical knowledge and practice.

Pre-Medication for Ketamine Sedation: Exploring New Research

One of the intriguing studies we covered this month examined pre-medication with midazolam or haloperidol for ketamine sedation. The randomized control trial suggested that pre-medication could reduce complications like abnormal behaviors and emergence phenomena. However, it also increased recovery time, requiring more resources and nursing time.

While the findings are interesting, they haven’t convinced us to change our current practice. However, it’s essential to stay informed about such research to make informed decisions in clinical practice.

HEMS and Traumatic Cardiac Arrest: Evaluating Outcomes

We also discussed the role of HEMS in improving outcomes for traumatic cardiac arrest. The study from the UK highlighted the high-level interventions provided by HEMS teams. However, it raised questions about the overall impact on patient survival. Of the 263 patients attended, only seven survived, and all had achieved ROSC before HEMS arrival. This data suggests that while HEMS interventions are critical, their direct impact on survival needs further evaluation.

This topic is sure to spark debate, and we appreciate the transparency of HEMS services in sharing their data and encouraging open discussions.

Looking Ahead: Plans for the Future

As we wrap up January, we’re excited about the plans for the coming months. Simon is heading to Jeddah for a significant event, and we’re considering hosting another St. Emlyn’s live conference and teaching course. We’re exploring innovative formats for medical conferences and welcome your ideas on how we can make these events even more impactful.

Support St. Emlyn’s: Keeping Education Free and Accessible

Since 2012, we’ve funded the blog and podcast out of our own pockets, but as our audience has grown, so have the costs. If you find our content valuable, please consider making a small donation or subscribing for regular contributions. Your support helps us keep St. Emlyn’s free and accessible to all.

Thank you for your time and continued support. Stay tuned for more updates, and as always, enjoy your emergency medicine practice and take care!

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

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

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

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

Understanding Devastating Brain Injury: Key Insights and Guidelines

In a recent episode of the St Emlyn's podcast, Simon Carley hosted experts Dan Harvey and Mark Wilson to discuss the intricacies of managing devastating brain injury (DBI). The conversation covered new guidelines, the challenges in prognostication, ethical considerations, and practical approaches in clinical settings. This blog post provides a comprehensive summary of their insights, focusing on the importance of standardized care, ethical decision-making, and the role of family involvement.

Defining Devastating Brain Injury

Devastating brain injury encompasses severe brain damage that often leads to significant long-term impairment or death. These injuries can result from various causes, including trauma, subarachnoid hemorrhage, hypoxic brain injury, and intracerebral hematomas. The term "devastating" highlights the severity of these injuries, but as discussed, the perception of devastation can vary, complicating management and prognostication.

The Challenge of Prognostication

One of the core issues in managing DBI is the variability in clinical practice across different healthcare settings. This inconsistency can lead to different outcomes depending on where the patient is treated. Dan Harvey emphasized that the new guidelines aim to standardize care, providing a consistent approach regardless of location. The guidelines recommend an observation period of up to 72 hours to gather comprehensive clinical data, crucial for making informed decisions.

Mark Wilson highlighted the difficulty in early prognostication, noting that initial presentations can be misleading. Factors such as intoxication, medication effects, or pre-existing conditions can obscure the true extent of brain injury. The term "perceived devastating brain injury" underscores the subjective nature of these assessments, stressing that what appears catastrophic on imaging may not always align with clinical outcomes.

The Role of Radiology and Clinical Assessment

Radiological findings, while essential, must be interpreted alongside clinical assessments. A severe CT scan may not always correlate with poor clinical outcomes, and vice versa. The discussion stressed the importance of not rushing to judgment based solely on initial imaging or clinical presentation. Recent studies, including those by Hanni Marcus and Mark Wilson, have shown that some patients with poor prognostic indicators can recover better than expected, particularly those with extra-axial hematomas.

Ethical Considerations and Family Involvement

Ethical considerations are paramount in managing DBI. The definition of a "good recovery" can vary widely among patients and families. For example, elderly patients with significant impairments may still value life, even with extensive care needs. The guidelines emphasize the importance of involving families in discussions about prognosis and treatment, ensuring decisions align with the patient's values and preferences.

Understanding the patient's and family's perspectives is crucial in determining the appropriate course of action. This holistic approach ensures that care decisions are not only medically sound but also ethically and personally appropriate. The discussion also highlighted the need for clear communication, helping families navigate complex and emotionally charged situations.

The Importance of Time and Observation

The guidelines advocate for a period of observation to avoid hasty decisions based on incomplete information. This period, typically up to 72 hours, allows for the identification and management of reversible factors, collection of comprehensive medical history, and better communication with the family. The aim is to reduce the risk of prematurely withdrawing life-sustaining treatment.

Practical Decision-Making

Determining the level of care for DBI patients involves deciding whether to transfer them to neurocritical care units or manage them in general ICUs. While specialized care offers advanced interventions like intracranial pressure (ICP) monitoring, evidence does not conclusively show that these measures always improve outcomes. The discussion acknowledged the limitations of resources and the importance of considering logistical factors, such as proximity to the patient's family.

The guidelines encourage clinicians to make informed decisions based on available evidence and specific case circumstances. They stress that not all DBI patients require transfer to specialized centers, especially when prognosis remains uncertain. The focus should be on providing essential life-saving therapies and monitoring the patient's condition.

Transitioning to Palliative Care

When recovery is deemed unlikely, transitioning to palliative care becomes a compassionate and appropriate choice. The guidelines stress the importance of clear communication with the family, ensuring they understand the prognosis and rationale behind limiting or withdrawing aggressive treatment. Palliative care focuses on symptom management, comfort, and supporting the patient and family, addressing not only physical but also emotional and psychological needs.

Organ Donation Considerations

Organ donation is an important consideration for DBI patients when the prognosis is poor. The guidelines recommend discussing this option with the family as part of end-of-life care planning. These discussions should be handled sensitively, providing clear information and respecting the family's wishes. Organ donation can provide hope and purpose in the face of tragedy, potentially saving other lives.

Conclusion and Key Takeaways

The St Emlyn's podcast episode on devastating brain injury provides crucial insights into the complexities of managing this challenging condition. The newly published guidelines offer a structured approach, emphasizing comprehensive assessment, ethical considerations, and family involvement.

Key Takeaways:

1. Standardize Practice: Reduce variability in DBI management by adhering to standardized guidelines, ensuring consistent and high-quality care.

2. Comprehensive Assessment: Utilize both clinical and radiological assessments to inform prognosis. Avoid premature conclusions based on incomplete data.

3. Ethical and Family Considerations: Engage with families to align treatment decisions with the patient's values and wishes. Provide clear, compassionate communication throughout the process.

4. Observation Period: Allow an appropriate observation period to clarify the patient's condition and potential for recovery.

5. Palliative Care: Transition to palliative care when necessary, prioritizing patient comfort and dignity.

6. Organ Donation: Discuss organ donation as part of end-of-life planning, handling these conversations with care and respect.

By following these guidelines, healthcare professionals can navigate the complexities of managing DBI with greater confidence and compassion, ultimately improving patient outcomes and supporting families through challenging times. For more detailed information and resources, visit the St Emlyn's blog and stay updated with the latest in emergency and critical care.

Exploring Emergency Medicine in South Africa: A Journey Beyond the Familiar

Introduction

Hello, and welcome to the St. Emlyn's podcast. I'm Simon Carley, and today, I'm sharing insights from a fascinating experience at the Emergency Medicine Society of South Africa (EMSSA) conference in Sunsetty, Johannesburg. The vibrant city became a backdrop for an enriching exploration into the challenges and rewards of practicing emergency medicine in a vastly different healthcare environment.

This blog post builds on Robert Lloyd's impactful blog about his tough yet enlightening experience at Khayelitsha Hospital. Our journey takes us through candid conversations with UK emergency medicine trainees currently working in South Africa. These discussions reveal not only the clinical and emotional challenges they face but also the profound personal growth they experience.

The Appeal of South African Emergency Medicine

Our conversation begins with a roundtable introduction. Each trainee shares their background and reasons for embarking on this journey. Jen, known as Coffee Headaches on Twitter, is currently working at Khayelitsha Hospital outside Cape Town, having moved from London. Chris and Chloe, both F4s, are working in Benedictine Hospital, Nongoma, and in Malawi, respectively. Sam, Jen's partner, is also at Khayelitsha, while Emma and Jacob, both F5s, are experiencing South African healthcare from different vantage points.

The primary motivation for these trainees to come to South Africa is to gain exposure to cases they rarely see in the UK. This includes a high prevalence of infectious diseases and trauma cases, providing a rich learning environment. The desire to challenge themselves and see how they react in a high-pressure environment is a compelling draw.

Realities of Practicing in South Africa

The conversation quickly shifts to the realities of working in this challenging environment. Despite extensive preparation, the reality of dealing with penetrating trauma, community assaults, and other interpersonal violence in South Africa is stark. As described by Jen and Chris, it's like managing a major incident every weekend night, with a constant flow of young male patients suffering from multiple stab wounds, often brought in by friends or local EMS.

The lack of resources and the necessity to make do with what's available forces a departure from UK-standard protocols. For instance, performing chest drains without the usual monitoring or resources becomes a norm. This scenario is a mental and emotional challenge, as it requires adapting to an environment where the ideal care isn't always possible.

Mental and Emotional Challenges

One of the key discussion points is the mental toll of practising in such a different environment. The trainees express that the most stressful aspect is not being able to provide the level of care they are accustomed to in the UK. The overwhelming number of patients and the lack of resources mean they must often prioritize care based on immediate necessity rather than best practice. This situation requires them to accept that they can't always do everything they would like to, a reality that is difficult to reconcile with their training.

Yet, they also speak of the incredible support network among South African doctors. These professionals guide the UK trainees, helping them navigate the practical challenges and the emotional landscape of emergency medicine in South Africa. This mentorship is invaluable, offering a buffer against the intense stress of the environment.

Unique Clinical Skills and Adaptations

The blog also delves into the unique clinical skills gained in South Africa. Many procedures and techniques, such as the Joburg knot for chest drains, are tailored to the local context, where resources are limited, and patients often face harsher post-treatment conditions. The trainees note that while these methods may not always align with UK standards, they are practical and effective in the South African context.

Moreover, they discuss the necessity of quick decision-making and improvisation. With patients often arriving in critical condition and space at a premium, immediate action is needed, often in less-than-ideal conditions. This experience contrasts sharply with the UK, where procedures are typically performed with more resources and time.

The Emotional Highs and Lows

Despite the challenges, the trainees describe the experience as overwhelmingly positive. The highs of successfully managing complex cases and the lows of resource limitations create a unique learning environment. The exposure to severe trauma cases, particularly penetrating injuries, has significantly reduced their anxiety about these scenarios. This newfound confidence is something they plan to bring back to their practice in the UK.

The trainees also express deep admiration for their South African colleagues, who demonstrate remarkable skill and resilience in a resource-limited setting. The ability of these professionals to provide high-quality care despite significant challenges is both inspiring and humbling.

Recommendations for Future Trainees

As the discussion winds down, the trainees share advice for others considering similar experiences. They emphasize the importance of understanding the expectations and conditions of the placement. The experiences can vary widely depending on whether one ends up in a well-supported trauma unit in a city or a rural hospital with minimal resources and support.

They recommend a minimum stay of three months to truly understand and contribute effectively to the healthcare setting. Shorter stays, they argue, don't provide enough time to adapt to the environment or make a meaningful impact.

Conclusion

Our conversation concludes with a reflection on the broader implications of this experience. The trainees agree that the skills and resilience developed in South Africa are not only invaluable but also applicable to emergency medicine practice in the UK. The experience underscores the need for adaptability, resourcefulness, and a deep understanding of the human aspects of healthcare.

South Africa, with its unique challenges and vibrant culture, offers an unparalleled learning experience for emergency medicine trainees. The personal and professional growth that comes from working in such a diverse and demanding environment is immense. As the trainees prepare to return to the UK, they carry with them not only new clinical skills but also a deeper understanding of themselves as clinicians.

This experience has been a powerful reminder that the essence of emergency medicine transcends geographical and cultural boundaries. It's about providing the best possible care under any circumstances, a lesson that resonates deeply with the core values of St. Emlyn's.

If you're considering a similar journey, take the plunge. The highs and lows are part of a journey that will not only shape your medical career but also broaden your perspective on healthcare and humanity. As we say goodbye to South Africa, the stories and lessons from this experience will undoubtedly inspire and inform the future of emergency medicine practice, both in the UK and beyond.

In this episode of the St Emlyn's podcast, Ian Beardsell and Simon Carley review the top 10 trauma papers of the year, highlighting key findings and their implications for trauma care. The selection includes significant studies published in high-profile journals such as The Lancet and the New England Journal of Medicine, offering valuable insights for healthcare professionals in emergency and trauma medicine.

1. Whole Body CT Scanning: REACT-2 Study

The REACT-2 study explored the impact of whole-body CT (WBCT) scanning on trauma patients, particularly its effect on mortality rates. The study involved 1400 patients and found no significant difference in mortality between those who received WBCT and those who underwent more selective CT scanning. The difference in radiation exposure was minimal, suggesting that WBCT's comprehensive imaging might be more beneficial than harmful, especially in elderly patients where missed injuries can complicate outcomes. This study reassures trauma team leaders that current scanning practices are appropriate and highlights the importance of a patient-centred approach based on clinical presentation.

2. Impact Brain Apnea (IBA)

Impact brain apnea, characterized by apnea and a catecholamine surge following a severe head blow, has been increasingly recognized in trauma care. The paper, co-authored by John Hines and Mark Wilson, provides a detailed explanation of IBA's pathophysiological mechanisms. This condition can lead to cardiac arrest if not promptly addressed, emphasizing the need for immediate intervention in cases of traumatic brain injury (TBI). Understanding IBA helps emergency care providers identify and treat potentially life-threatening conditions that may not be immediately apparent.

3. Decompressive Craniectomy for Raised ICP: RESCUE-ICP Trial

The RESCUE-ICP trial examined the outcomes of decompressive craniectomy in patients with refractory intracranial pressure (ICP) due to severe TBI. The study found that while the procedure increased survival rates, many survivors experienced significant disability. This raises ethical considerations about the quality of life post-intervention. The trial underscores the importance of informed consent and discussions about potential outcomes with patients' families, aligning treatment with patient values.

4. STITCH Trial: Surgery Timing for Intracranial Bleeds

The STITCH trial focused on the timing of surgical intervention in patients with traumatic intracranial bleeds. Although the trial faced recruitment challenges and was terminated early, results suggested better outcomes with early surgery. This finding, while not statistically conclusive, supports the notion that timely intervention can reduce mortality and improve recovery. Emergency physicians and neurosurgeons should consider these findings when deciding on surgical timing in TBI cases.

5. Traumatic Cardiac Arrest: Epidemiology and Outcomes

Using data from the Trauma Audit and Research Network (TARN), this study examined traumatic cardiac arrest (TCA) cases, revealing a 30-day survival rate of 7.5%. This rate, similar to medical cardiac arrests, challenges the perception that TCA is almost always fatal. The study highlights the importance of aggressive resuscitation efforts and underscores the need for ongoing training to retain skills in managing these rare but critical events.

6. Open vs. Closed Chest Compressions in TCA

The effectiveness of open chest (thoracotomy) versus closed chest compressions in TCA was explored, with findings indicating similar outcomes in terms of end-tidal CO2 levels, a marker for effective CPR. This challenges the notion that thoracotomy should always be performed in TCA cases. The study suggests that standard advanced life support (ALS) protocols may suffice in certain scenarios, especially where thoracotomy is not practical.

7. Rocuronium vs. Succinylcholine for RSI in Severe Brain Injury

The choice between rocuronium and succinylcholine for rapid sequence intubation (RSI) in severe brain injury remains debated. An observational study found no significant overall difference in mortality between the two drugs, though succinylcholine was associated with higher mortality in severe head injury cases. This suggests a possible preference for rocuronium in such scenarios, though the evidence is not strong enough to mandate a change in practice.

8. Intraosseous Needle Length in Obese Patients

As obesity becomes more prevalent, appropriate intraosseous (IO) needle length is crucial for effective vascular access. The study recommended using longer yellow IO needles for patients with a BMI over 43, as standard blue needles may not reach the marrow. This is particularly important in emergency situations where IV access is difficult, ensuring proper drug administration and preventing complications like compartment syndrome.

9. Optimal Site for Needle Decompression in Tension Pneumothorax

A systematic review recommended the anterior axillary line as the preferred site for needle decompression in tension pneumothorax, aligning with standard chest drain placement. The review also noted significant complication rates associated with needle decompression, suggesting that alternative methods like thoracostomy may be necessary in certain cases. This finding emphasizes the need for precise technique and careful consideration in managing tension pneumothorax.

10. Weekend Effect in Major Trauma Care

The study examined the "weekend effect" in major trauma care, finding no significant difference in mortality between weekend and weekday admissions. This suggests that well-resourced, consultant-led trauma care can provide consistent outcomes regardless of the day. The findings advocate for the 24/7 availability of senior emergency physicians and trauma teams, ensuring high-quality care at all times.

Conclusion

This year's top trauma papers provide valuable insights into current practices and emerging trends in trauma care. While there may not have been groundbreaking changes, the studies reinforce the importance of evidence-based decision-making, ongoing training, and ethical considerations in patient management. As the field evolves, staying informed about the latest research is crucial for improving patient outcomes and delivering high-quality trauma care. For further details and access to the studies, visit the Sentemlin site and related FOAMed resources.

Nat and Simon discuss the complexities of transferring a patient from the resus room to CT and back again. Look out for the blog post soon on stemlynsblog.org

Title: Mastering Chest Drains: Essential Tips and Techniques for Emergency Medicine

In this comprehensive guide, Simon Carley and Rick Bodey from St Emlyns explore the essential aspects of chest drains, also known as intercostal drains or chest tubes, focusing on their importance, optimal techniques, and common pitfalls in emergency medicine.

Importance of Chest Drains

Chest drains are critical for managing conditions like pneumothorax, hemothorax, and pleural effusion by removing air, blood, or fluid from the pleural cavity. Despite not being a daily procedure in the UK, proficiency in chest drain insertion is crucial due to the potential for severe complications, including organ damage and infection. Proper training and careful execution are necessary, especially as new technologies and medical practices evolve.

Choosing the Right Size

Traditionally, large-bore drains (32-36 French) were used for pneumothoraces to prevent blockage by clots. However, recent evidence supports the use of smaller drains (28-32 French), even for trauma patients. Smaller drains are less invasive, cause less discomfort, and are equally effective. The move towards smaller drains aligns with a trend in medicine favoring minimally invasive procedures, which reduce patient risk and enhance comfort.

Management of Occult Pneumothoraces

Advances in imaging, like CT scans and ultrasound, have increased the detection of occult pneumothoraces, which are often asymptomatic and not visible on chest x-rays. Traditional guidelines recommended chest drains for all traumatic pneumothoraces, but recent research suggests conservative management may be appropriate in many cases. A systematic review found no significant difference in outcomes between patients with occult pneumothoraces managed conservatively and those who received chest drains. This highlights the importance of assessing each patient's condition, monitoring closely, and only intervening when necessary, particularly in stable, asymptomatic patients.

Optimizing Analgesia

Pain management during chest drain insertion is vital. Traditional local anesthesia methods are often insufficient, especially in trauma settings. Ketamine has emerged as an effective option, providing both analgesia and sedation without significant respiratory depression. Administered in small, incremental doses, ketamine helps manage pain and anxiety, making the procedure more tolerable. Additional analgesics, like fentanyl and midazolam, can complement ketamine, offering a multimodal approach to pain management.

Intra-Pleural Analgesia

Injecting local anesthetics, such as bupivacaine, into the pleural cavity can further enhance patient comfort, particularly as the lung re-expands and contacts the parietal pleura. This method is supported by randomized controlled trials and can significantly reduce pain in the first few hours post-insertion, aiding in better respiratory function and reducing the risk of complications like pneumonia.

Securing the Drain

Properly securing the chest drain is crucial to prevent accidental dislodgement, especially during patient transport or imaging. Techniques like Neil Bandari's "Jo'burg knot" offer reliable methods for securing drains, though simpler techniques may suffice for less frequent practitioners. Transparent dressings are recommended to allow monitoring of the insertion site and ensure the drain remains securely anchored.

The Role of Ultrasound

Ultrasound is an invaluable tool for accurately placing chest drains, particularly in cases of pleural effusion or complex pleural anatomy. It aids in identifying the best insertion site, reducing the risk of complications, and confirming the resolution of pneumothorax. Ultrasound is especially useful in patients with obesity or chronic lung conditions, where traditional landmarks may not be reliable.

Aspiration of Pneumothoraces

For primary spontaneous pneumothoraces, aspiration may be a viable alternative to chest drain insertion, particularly when specific criteria are met. This less invasive approach can be performed with a standard IV cannula or a small Seldinger technique, which also provides a pathway for chest drain insertion if necessary. This method is beneficial in outpatient settings, allowing for quick resolution without hospitalization.

Conclusion

The management of chest drains is a dynamic field, continually evolving with new research and technology. Emergency medicine practitioners must stay informed and adapt to evidence-based practices, including the use of smaller chest drains, conservative management of occult pneumothoraces, optimized analgesia, and the application of ultrasound. The goal is to provide safe, effective, and patient-centered care, minimizing unnecessary interventions.

At St Emlyns, we strive to share knowledge and best practices to enhance patient care. We invite our readers to contribute their insights and experiences, fostering a collaborative approach to improving clinical skills and outcomes in emergency medicine.

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.

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

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

A 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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Exciting Collaboration Between St Emlyns and the London Trauma Conference

Welcome to the latest St Emlyns podcast! I'm Iain Beardsell, and alongside Natalie Mace, we are thrilled to announce an exciting new collaboration between the St Emlyns team and the London Trauma Conference. This esteemed conference will take place in London next week, and we've been honored with the opportunity to attend as members of the press. We will be interviewing some of the prominent speakers participating in the event, marking a significant first for our team at St Emlyns.

The London Trauma Conference: Dates and Highlights

The London Trauma Conference is scheduled from Tuesday, December 9th to Thursday, December 11th. This three-day event promises a stellar lineup of speakers from the Trauma World, including sessions on Trauma Surgery, Trauma Nursing, and a dedicated day for trainees. There’s even a special Thoracotomy day planned. This comprehensive program ensures there’s something for everyone in the field of trauma care.

Why Attend the London Trauma Conference?

We are not just attending to listen; our goal is to bring you the inside stories and insights from the speakers after their sessions. We aim to ask the questions you want answers to, making this conference more interactive and engaging for all of us. Whether you are a seasoned professional or a trainee, this conference offers invaluable knowledge and networking opportunities.

If you’re considering attending, we highly encourage it. You can find all the details and register at www.londontraumaconference.com. There are still places available, so don’t miss out on this exceptional event.

Engaging with the Conference Online

For those who can't make it to London, there are still plenty of ways to stay involved. Follow along on Twitter using the hashtag #ltc2014. We will be tweeting live updates from the sessions, and you can tweet your questions to us. We’ll do our best to catch up with the speakers and get your questions answered.

Getting Ready for Trauma Week

To get in the mood for the upcoming trauma week, we recommend listening to "The Fight for Life," a program by Kevin Fong on BBC Radio 4. This enlightening show traces the origins of trauma care and brings it up to the modern day. Kevin speaks with James K. Steiner, the American orthopedic surgeon who designed the ATLS course after his family was involved in a tragic air accident. The program is both moving and inspiring, highlighting the importance of coordinated trauma care.

Meet the Speakers: Friends of St Emlyns

We are excited to reconnect with many friends of St Emlyns at the conference. Among the notable speakers are Mark Wilson, a renowned neurosurgeon from London, and Karen Brodie, a respected vascular and trauma surgeon. Ross Fisher, a pediatric surgeon from Sheffield, will be discussing pediatric trauma. Additionally, our colleagues from Sydney Hems, including Cliff Reed and Brian Burns, will also be presenting. The lineup reads like a who's who of UK and international trauma medicine, ensuring a wealth of knowledge and experience will be shared.

Our Mission at St Emlyns

At St Emlyns, we are dedicated to spreading trauma care education as widely as possible. None of our team members have any financial interest in the conference; our goal is purely educational. We hope to learn and share valuable insights with you, our community, to enhance our collective understanding and capabilities in trauma care.

Welcoming New Doctors to Emergency Medicine

This week is particularly special as it marks the arrival of new doctors in our emergency departments across the UK. This transition happens four or five times a year, bringing fresh faces, enthusiasm, and, understandably, a bit of nervousness. We urge everyone to extend kindness and support to these junior doctors. Our emergency departments thrive on a culture of learning and collaboration, and it’s essential to make our new colleagues feel welcome and valued.

If you are one of these new doctors, make sure to check out our induction blog posts and podcasts. They are available on the St Emlyns blog at stemlynsblog.org and on our iTunes podcast feed. These resources are designed to help you navigate the initial challenges and embrace the exciting journey ahead in emergency medicine.

The Importance of Continued Learning in Emergency Medicine

As we see from the current news, it’s a challenging time for UK emergency medicine. However, at St Emlyns, we are committed to bringing you the best resources, insights, and inspiration to help you continue delivering exceptional care to your patients. Our collaboration with the London Trauma Conference is just one example of our efforts to enhance the education and support available to all healthcare professionals in our community.

Conclusion

We are incredibly excited about this new venture and look forward to sharing our experiences and learnings from the London Trauma Conference with you. Whether you join us in person or follow along online, we hope this event will be as enlightening and inspiring for you as it promises to be for us.

Thank you for being a part of the St Emlyns community. Please continue enjoying your work in emergency medicine, and we’ll be back with more updates and insights very soon. Take care and thanks for listening!